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Background: Pediatric heart transplantation is a now a well-established and standard treatment option for end stage heart failure for various conditions in children. Due to logistic issues, it is not an option for in most pediatric cardiac centres in the third world. Aim: We sought to describe our early experience in the current era in India. Methods: This is a short term retrospective chart review of pediatric patients who underwent heart transplantation at our centre. Mean/Median with standard deviation /range was used to present data. Results: Twenty patients underwent orthotopic heart transplant between January 2016 and June 2019. The median age at transplant was 12.4years (range 3.3 to 17.3 years). The median weight was 23.2kg (range 10-80kg). The mean donor/recipient weight ratio was 1.62± 0.84. The mean ICU stay was 12.1days. The mean follow up post transplant was 2.03± 0.97years (range 10 days-3.57years). The 1 month and the 1 year survival was 100%. Biopsies were positive for significant rejection in 7 patients (35%). At the time of last follow-up, 3 patients (15%) had expired. The major post transplant morbidities were mechanical circulatory support (n=3), hypertension with seizure complex (n=3), post transplant lympho-proliferative disorder (n=1), pseudocyst of pancreas (n=1), coronary allograft vasculopathy (n=3) and systemic hypertension (n=7). All surviving patients (n=17) were asymptomatic at last follow up. Conclusion: The results suggest acceptable short term outcomes in Indian pediatric patients can be achieved after heart transplantation in the current era. Significant rejection episodes and coronary allograft vasculopathy need careful follow up.

Purpose: To evaluate the diagnostic test properties of the Palm Scan VF2000® Virtual Reality Visual Field Analyzer for diagnosis and classification of the severity of glaucoma. Methods: This study was a prospective cross-sectional analysis of 166 eyes from 97 participants. All of them were examined by the Humphrey® Field Analyzer (used as the gold standard) and the Palm Scan VF 2000® Virtual Reality Visual Field Analyzer on the same day by the same examiner. We estimated the kappa statistic (including 95% confidence interval [CI]) as a measure of agreement between these two methods. The diagnostic test properties were assessed using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results: The sensitivity, specificity, PPV, and NPV for the Virtual Reality Visual Field Analyzer for the classification of individuals as glaucoma/non-glaucoma was 100%. The general agreement for the classification of glaucoma between these two instruments was 0.63 (95% CI: 0.56–0.78). The agreement for mild glaucoma was 0.76 (95% CI: 0.61–0.92), for moderate glaucoma was 0.37 (0.14–0.60), and for severe glaucoma was 0.70 (95% CI: 0.55–0.85). About 28% of moderate glaucoma cases were misclassified as mild and 17% were misclassified as severe by the virtual reality visual field analyzer. Furthermore, 20% of severe cases were misclassified as moderate by this instrument. Conclusion: The instrument is 100% sensitive and specific in detection of glaucoma. However, among patients with glaucoma, there is a relatively high proportion of misclassification of severity of glaucoma. Thus, although useful for screening of glaucoma, it cannot replace the Humphrey® Field Analyzer for the clinical management in its current form.

To compare the effect of intravenous or intra-articular route of administration of tranexamic acid in reducing the blood loss in simultaneous bilateral total knee replacement surgeries performed without the use of tourniquets. Prospective cohort study of 30 consecutive patients grouped into two groups; Group 1: intravenous group and group 2: intra-articular group. Two outcome measures were studied; mean drop in post-operative haemoglobin and need for blood transfusion in both groups. No significant difference in mean drop of haemoglobin and need for blood transfusion in both groups. Route of administration of tranexamic acid does not influence on the mean drop of haemoglobin and need for blood transfusion in simultaneous bilateral total knee replacement surgeries performed without the use of tourniquet.

Jet lag is one of those common medical problems, to which most people don't give a serious thought. However, it is intricately intertwined with our normal circadian rhythm. It is classified as a sleep disorder. There is also a dearth of good scientific literature, not to mention clinical trials on the subject. Slowly but steadily, the scientific community is realizing the various deleterious health effects of jet lag and is devising innovative methods to counter them. This narrative review touches upon the etiopathogenesis, clinical manifestations and therapeutic strategies effective against the nagging problem of jet lag.

Study Design:Prospective cohort study.Objectives:The objectives of this study were (1) to determine the characteristics of patients sustaining spinal trauma in India and (2) to explore the associat...

Papillary fibroelastomas (PFEs) are the second most common benign neoplasms of the cardiac valves and are being recognized more frequently because of higher resolution imaging technology. PFEs are associated with substantial complications that are secondary to systemic embolism. Surgical resection should be offered to all patients who have symptoms and to asymptomatic patients who have pedunculated lesions or tumors larger than 1 cm in diameter. Herein, we present a patient who presented for a second time in 2 months with stroke symptoms. During his first admission, a transthoracic echocardiogram was performed and he was sent home after resolution of his symptoms and a grossly negative workup. During his second admission, a transesophageal echocardiogram was performed and the PFE was found and later excised. While this discussion reviews the literature with regard to detection and management, it will hopefully serve as a reminder to keep this on the differential when the workup has remained without an obvious source.

Introduction: To compare pain scores at rest and ambulation and to assess patient satisfaction between the different modalities of pain management at different time points after surgery. Settings and Design: The ASSIST (Patient Satisfaction Survey: Pain Management) was an investigator-initiated, prospective, multicenter survey conducted among 1046 postoperative patients from India. Material and Methods: Pain scores, patient's and caregiver's satisfaction toward postoperative pain treatment, and overall pain management at the hospital were captured at three different time points through a specially designed questionnaire. The survey assessed if the presence of acute pain services (APSs) leads to better pain scores and patient satisfaction scores. Statistical Analysis: One-way ANOVA was used to evaluate the statistical significance between different modalities of pain management, and paired t-test was used to compare pain and patient satisfaction scores between the APS and non-APS groups. Results: The results indicated that about 88.4% of patients reported postoperative pain during the first 24 h after surgery. The mean pain score at rest on a scale of 1–10 was 2.3 ± 1.8 during the first 24 h after surgery and 1.1 ± 1.5 at 72 h; the patient satisfaction was 7.9/10. Significant pain relief from all pain treatment was reported by patients in the non-APS group (81.6%) compared with those in the APS (77.8%) group (P < 0.0016). Conclusion: This investigator-initiated survey from the Indian subcontinent demonstrates that current standards of care in postoperative pain management remain suboptimal and that APS service, wherever it exists, is yet to reach its full potential.

Henoch-Schonlein Purpura (HSP) is an IgA mediated vasculitis predominantly affecting the pediatric population. This disease may leave a lifelong residual effect on renal system with a propensity for a relapse during pregnancy leading to hypertensive and hemorrhagic complications. We present a case of a patient who had HSP in adulthood and had uncomplicated caesarean delivery under regional anesthesia.

Capecitabine is a pyrimidine analogue used as an anti‐neoplastic agent. It is a fluoropyrimidine‐based oral prodrug of 5‐fluorouracil (5‐FU). It exerts its effect by selectively activating a three step enzymatic pathway. The last step is catalysed by the enzyme thymidine phosphorylase 1. As compared to normal tissues, this enzyme has higher activity in neoplasms than in normal tissues. Hence, 5‐FU tends to accumulate in tumour cells. Capecitabine is currently approved for treatment of metastatic breast cancer and is included in the WHO list of essential medicines. Though 5‐FU has been associated with cardiotoxicity, there have only been a handful of reports linking capecitabine to cardiac dysfunction. Generally speaking, capecitabine is known as a relatively safe drug. However, the most common reversible side effects are hand–foot syndrome (17%), gastrointestinal upset (17%), and nausea (15%) 1. Though 5‐FU has been associated with cardiotoxic effects, capecitabine‐induced myocardial toxicity is rare and has not been much reported. Its incidence is on the rise due to a burgeoning geriatric population and more widespread use of capecitabine 2. In this case report, we describe a male with metastatic breast cancer and no pre‐existing heart disease, who was being treated with capecitabine. Before initiation of chemotherapy, his cardiac function was normal with an ejection fraction of 70%. However, over the next 12 months, he developed progressive exertional dyspnoea. Repeat Transthoracic Echocardiography (TTE) revealed an ejection fraction of 10%.

Solid organ transplants are slowly increasing across the world. As the societies evolve and communities begin to realize the value of organ donation after brain death, the number of donations after brain death will continue to the rise. These numbers, however, encouraging are far inadequate to meet the demands from the ever-growing number of recipients. This gap is filled in some measure by live donors who are subjected to an invasive procedure to provide kidneys, part of the liver, or even lung. In comparison, the patients with end-stage heart disease have no such options and continue their vigil on the waiting list. This has also led to a huge increase in the number of implantable devices like the left ventricular assist device in developing countries in recent times.

Gordonia is a catalase-positive, aerobic, nocardioform, Gram-positive staining actinomycete that also shows weak acid-fast staining. Several Gordonia species are commonly found in the soil. The bacterium has been isolated from the saliva of domesticated/wild dogs as well. In hospitalized patients, most commonly it is found in the setting of intravascular catheter-related infections. However, recent reports show that it is being increasingly isolated from sternal wounds, skin/neoplastic specimens and from pleural effusions. Gordonia shares many common characteristics with Rhodococcus and Nocardia. Ergo, it is commonly misrecognized as Nocardia or Rhodococcus. Since this pathogen requires comprehensive morphological and biochemical testing, it is often difficult and cumbersome to isolate the species. Broad-range Polymerase Chain Reaction (PCR) and sequencing with genes like 16S rRNA or hsp65 are used to correctly identify the species. Identification is essential for choosing and narrowing the right antimicrobial agent. Herein, we report our experience with a patient who presented with sternal osteomyelitis after infection with this elusive bug.

Purpose: The aim of this study is to evaluate the accuracy of three newer generation formulae (Barrett Universal II, EVO, Hill-RBF 2.0) for calculation of power of two standard IOLs—the Acrysof IQ and Tecnis ZCB00 across all axial lengths. Methods: In this retrospective series, 206 eyes of 206 patients, operated for cataract surgery with above two IOLs over the last 6 months, were included in the study. Preoperative biometry measurements were obtained from LenstarLS900. By using recommended lens constants, the mean error for each formula was calculated and compared. Then, the optimized IOL constants were calculated to reduce the mean error to zero. Mean and median absolute errors were calculated for all eyes and separately for short (AL24.5 mm). Absolute errors and percentages of eyes within prediction errors of ±0.25 D, ±0.50 D, ±0.75 D, and ±1.00 D were compared. Results: Prediction error with using recommended lens constants was significantly lower in the Barrett Universal II formula as compared to the other two formulae. However, after optimizing lens constants, there were no significant differences in the absolute errors between the three formulae. The formulae ranked by mean absolute error were as follows: Barrett Universal II (0.304 D), EVO (0.317 D), and Hill-RBF (0.322) D. There were no significant differences between absolute errors in the three formulae in each of the short-, medium-, and long-eye subgroups. Conclusion: With proper lens constant optimization, the Barrett Universal II, EVO, and Hill-RBF 2.0 formulae were equally accurate in predicting IOL power across the entire range of axial lengths.

Current mainstay treatment for pulmonary embolism (PE) includes oral anticoagulation, thrombolytic therapy, catheter embolectomy and acute surgical embolectomy. Surgical embolectomy is reserved for hemodynamically unstable patients (cardiogenic shock, cardiac arrest) and contraindication to thrombolytic therapy. We report a case of saddle PE in a young female with echocardiographic signs of right ventricular (RV) dysfunction who underwent early acute surgical embolectomy with a positive outcome. It would be beneficial to use bedside echocardiography even in hemodynamically stable patients to determine RV strain as this could act as an early indicator suggesting the escalation of therapy.

Left ventricular noncompaction cardiomyopathy is a rare myocardial disorder which results from failure of left ventricle to compact in embryogenesis. We present a case of a 53-year-old female who came because of abdominal pain and was found to have renal infarct secondary to noncompaction cardiomyopathy.

Background. Obstructive sleep apnea (OSA) is a chronic respiratory disorder associated with repeated nocturnal partial or complete collapse that is often underdiagnosed and associated with multiple comorbidities. The association between specific features on an electrocardiogram and OSA has not been well studied. This retrospective study attempts to bridge this gap in knowledge.Methods. A total of 265 patients’ medical records were reviewed retrospectively. Specific features of their electrocardiograms and their association with the severity of OSA were studied from April 2014 to May 2016. 215 patients were included in the final analysis. Tests of group difference between OSA patients and controls were done using student’s t-tests for continuous variables and using chi-square tests for categorical outcomes. Multivariate tests of differences between OSA and control patients were done using logistic regression to control for possible confounding factors.Results. A total of 215 patients with diagnosed OSA and 41 controls in whom OSA was ruled out using polysomnography were compared. Males were more likely to present with OSA than females (93 % versus 76 %; p < 0.001). OSA patients were also significantly older: 52.18 ± 14.04 versus 44.55 ± 14.64; p = 0.002. Deep S waves in V5-6 (p=0.014) and RS pattern with Deep S waves in leads I and AVF (p=0.017) were both significantly associated with OSA based on univariate comparisons. These findings lost significance in the multivariate analysis.Conclusion. The idea of using an electrocardiogram in aiding in the assessment of OSA is attractive and feasible, as it is a safe, noninvasive, and cost-effective method. Our results can be used for early risk stratification in patients with OSA.

Congestive heart failure (CHF) is a chronic disease process affecting multiple organ systems and is associated with significant morbidity and mortality. We report a case of a 43-year-old male with a history of unspecified cardiomyopathy who presented to the hospital with abdominal pain, distention, and nausea for 4 months. He was diagnosed with left ventricular noncompaction and gastroparesis. While symptoms of dyspnea, orthopnea, or increasing peripheral edema are the first that come to mind when thinking of a CHF exacerbation, we must broaden our scope to include such things as nausea, vomiting, abdominal pain, and bloating which can also indicate worsening cardiac function. This case report highlights the significant yet often forgotten gastrointestinal (GI) symptoms that result from advanced biventricular heart failure, with emphasis on impaired gastric and intestinal motility.

It is vital to recognize correctly, chest pain of cardiac etiology. Most commonly, it is because of blood supply-demand inequity in the myocardium. However, the phenomenon of myocardial bridging as a cause of cardiac chest pain has come to attention reasonably recently. Herein, a coronary artery with a normal epicardial orientation develops a transient myocardial course. If the cardiac muscle burden is substantial, the respective artery gets compressed during each cycle of systole, thereby impeding blood flow in the artery. Hence, myocardial bridging has been attributed to as a rare cause of angina. In this case report, the authors discuss a patient in whom myocardial bridging turned out to be an elusive cause of angina. We wish to underscore the importance of being clinically mindful of myocardial bridging when assessing a patient with angina.

The number of patients with advanced heart failure receiving left ventricular assist device (LVAD) implantation has increased dramatically over the last decade. There are limited data available about the nationwide trends of complications leading to readmissions following implantation of contemporary devices. Patients undergoing LVAD implantation from January 2013 to December 2013 were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code 37.66 from the healthcare cost and utilization project’s (HCUP) National Readmission Database (NRD). The top causes of unplanned 30-day readmission after LVAD implantation were determined. Survey logistic regression was used to analyze the significant predictors of readmission. In 2013, there were 2,235 patients with an LVAD implantation. Of them, 665 (29.7%) had at least one unplanned readmission within 30 days, out of which 289 (43.4%) occurred within 10 days post discharge. Implant complications (14.9%), congestive heart failure (11.7%) and gastrointestinal bleeding (8.4%) were the top 3 diagnoses for the first readmission and accounted for more than a third of all readmissions. Significant predictors of readmissions included a prolonged LOS during the index admission, Medicare insurance, and discharge to short term facility. In conclusion, despite increased experience with LVADs, unplanned readmissions within 30 days of implantation remain significantly high.

A 49-year-old African American male patient with no past medical history was admitted because of 3 months of difficulty swallowing solid and liquid foods. He had constant retrosternal discomfort and appeared malnourished. The chest radiograph revealed a right sided aortic arch with tracheal deviation to the left. A swallow study confirmed a fixed esophageal narrowing at the level of T6. Contrast enhanced Computed Tomography (CT) angiogram of the chest and neck revealed a mirror image right aortic arch with a left sided cardiac apex and a prominent ductus diverticulum (measuring 1.7 × 1.8 cm). This structure extended posterior to and indented the mid esophagus. A left posterolateral thoracotomy was performed and the ductus diverticulum was resected. A retroesophageal ligamentum arteriosum was found during surgery and divided. This rare combination of congenital anatomical aberrations led to severe dysphagia in our patient. Successful surgical correction in the form of resection of the ductus diverticulum and division of the retroesophageal ligamentum arteriosum led to complete resolution of our patient’s symptoms.

Background Plantar fasciitis is one of the commonest, and most frustrating, foot ailments seen in a regular orthopaedic clinic. There are a number of modalities available to treat this condition, of which corticosteroid injection is, perhaps, the most popular. However, recent years have seen an increased interest in the use of platelet-rich plasma (PRP) injections in various clinical situations such as plantar fasciitis. Methods We undertook a prospective non-randomized study to compare the efficacy of traditional corticosteroid injection (Steroid group) to PRP injection (PRP group), in a cohort of patients. Results We studied both groups of patients before and after the injections using Visual Analogue Score (VAS), the Foot & Ankle Disability Index (FADI) and American Foot and Ankle Score (AFAS). Our study confirms that there is significant clinical improvement in PRP group at three months after the injection. Conclusion The use of PRP injection can be an attractive alternative in the treatment of disabling, recalcitrant plantar fasciitis. Study design Cohort study. Level of clinical evidence Level 3.

Orthobiologics have evolved to the extent that they significantly influence modern orthopedic surgical practice. A better understanding of the role of various growth factors and cells in the process of tendon healing, ligament repair, cartilage regeneration and bone formation has stimulated focused research in many chronic musculoskeletal ailments. Investigators have published results of laboratory as well as clinical studies, using orthobiologics like platelet rich plasma, stem cells, autologous conditioned serum etc., with variable results. However, a clear consensus over the best orthobiologic substance and the method of preparation and usage of these substances is lacking. Much of the confusion is due to the fact that studies ranging from RCTs to case reports present variable results, and the interpretations are wide-ranging. We have reviewed the available orthobiologics related data with a focus on platelet rich plasma in orthopedic conditions.

Background: Ultrasound (US)-guided internal jugular vein (IJV) cannulation is a widely accepted standard procedure. The axillary vein (AV) in comparison to the subclavian vein is easily visualized, but its cannulation is not extensively studied in cardiac patients. Aims: This study is an attempt to study the efficacy of real-time US-guided axillary venous cannulation as a safe alternative for the time-tested US-guided IJV cannulation. Design: This is a prospective randomized controlled study. Materials and Methods: A total of 100 adult patients scheduled for cardiac surgery were divided equally in Group A-US-guided IJV cannulation, and Group B-US-guided axillary venous cannulation. Under local anesthesia and real-time US guidance the IJV or AV was secured. The access time, guidewire time, and procedure time were noted. Furthermore, the number of needle attempts, malposition, change of site, and complications were noted. Results: The data were analyzed for 49 patients in Group A and 48 patients in the Group B due to exclusions. The access time and the guidewire time were comparable in both groups. The first attempt needle puncture was successful for the IJV group in 98% of patients in comparison to 95% of patients in Group B. Guidewire was passed in the first attempt in 94% in Group A and 89% in the Group B. Except for arterial puncture in one case in group A, the complications were insignificant in both groups. Conclusion: The study shows that the US-guided AV cannulation may serve as an effective alternative to the IJV cannulation in cardiac surgery.

A 44-year-old Hispanic woman presented to the emergency room with a 2-day history of sudden onset of severe cramping left lower quadrant abdominal pain associated with ∼20 episodes diarrhoea. Abdominal CT scan exhibited bowel wall oedema and acute extensive colitis. On the basis of the preliminary diagnosis of acute abdomen, the patient was admitted under the surgical team and treated for acute colitis. Since her family history was significant for hereditary angioedema (HAE), complement studies were performed which revealed low complement C4 levels and abnormally low values of C1q esterase inhibitor. Thus, the diagnosis of HAE type I was established. This case report summarises that the symptoms of HAE are often non-specific, hence making the underlying cause difficult to diagnose.

The Babinski Sign is one of the most clinically relevant diagnostic signs in medicine. Though the plantar reflex is practiced thousands of times across the globe every day, few realize its historical importance. In this narrative review we trace the origins of the Plantar Reflex back in the 19th century, discuss its evolution over time and examine the body of evidence behind the current understanding. State of the art diagnostic modalities like video analysis and electromyography have helped us in dissecting the pathophysiology behind the simple yet beautiful Babinski Sign.

Nanomedicine is one of the most promising therapeutic modalities researchers are working on. It involves development of drugs and devices that work at the nanoscale (10–9 m). Coronary artery disease (CAD) is responsible for more than a third of all deaths in age group >35 years. With such a huge burden of mortality, CAD is one of the diseases where nanomedicine is being employed for preventive and therapeutic interventions. Nanomedicine can effectively deliver focused drug payload at sites of local plaque formation. Non-invasive strategies include thwarting angiogenesis, intra-arterial thrombosis and local inflammation. Invasive strategies following percutaneous coronary intervention (PCI) include anti-restenosis and healing enhancement. However, before practical application becomes widespread, many challenges need to be dealt with. These include manufacturing at the nanoscale, direct nanomaterial cellular toxicity and visualization.

Fractures of the distal radius in elderly patients are often associated with metaphyseal defects that can lead to collapse, malunion and therefore decreased function. An alternative approach to simple reduction is to fill the defects with materials that can provide structural support. We used synthetic hydroxyapatite (HA) in unstable fractures of the distal radius in thirty-one elderly patients, of which four patients lost to follow-up, leaving twenty-seven patients for this study. All subjects underwent closed reduction with K-wire fixation and HA augmentation. They were followed up at 8- and 16-week intervals post-operatively to assess the functional outcome using patient-related wrist evaluation [PRWE], clinical outcome and radiological outcome. At mean 16 weeks, our results show that patients treated with this method showed no metaphyseal defect, no collapse and had satisfactory clinical outcome as assessed by PRWE. We believe that fixation with hydroxyapatite augmentation for fractures of the distal radius in elderly patients is an attractive therapeutic option. This experience has changed our clinical practice.

It has been nearly a century that medical community is discussing the existence of plica as a cause of knee pain. Still consensus has not been achieved over the management of this condition. Plicae are normal synovial infolds of the joint capsule, considered to be vestigial in nature, but can become symptomatic. We often get patients specially young and active adults with anteromedial pain of knee joint in our clinic. Injury to knee joint frequently precedes the development of symptoms, but regular overuse and chronic synovitis can also lead to pathological medial plica. Various etiological factors convert the normal elastic nature of medial plica to thick fibrous structure. This fibrotic band causes mechanical irritation and is also responsible for focal secondary chondromalacia. Clinical evaluation, history, and thorough examination of knee joint are necessary to establish the diagnosis and exclude other related pathological conditions. Various provocative tests that reproduce patient’s symptoms and a system to diagnose medial plica syndrome based on history and clinical examination have been described in literature. Newer imaging techniques, which are less hazardous and noninvasive, like dynamic ultrasonography and magnetic resonance imaging, are emerging as useful tools in diagnosing medial plica syndrome. Arthroscopy is the gold standard modality in diagnosing as well as treating the condition. It offers surgeons to inspect whole joint and assess personality of plica and resection in same session. Conservative therapy has a place in the management but arthroscopic complete excision of pathological medial plica provides excellent results.

Although there is general consensus about the efficacy of total hip replacement (THR) in young patients, the most appropriate bearings in young patients remain highly debated. The three most popular bearings in use include metal-on-polyethylene (MOP), metal-on-metal (MOM) and ceramic-on-ceramic (COC). We conducted a systematic review and meta-analysis of literature to summarise the best available evidence on relative success of the three most popular bearings used in THR in young active patients. Our findings support the use of MOM bearings in the management of the young arthritic hip. These findings, largely based upon observational studies, should be taken in the context of the limitations of such non-randomised study designs.

Guidelines recommending various nonoperative treatments for patients with knee osteoarthritis remain inconsistent. Much of this controversy relates to what constitutes a clinically important effect. The purposes of the present study were to compare treatment effect sizes from recent meta-analyses evaluating pharmacological or medical device interventions for the treatment of knee osteoarthritis and to further assess the clinical impact that the intra-articular placebo effect may have on intra-articular injection therapies.A search of PubMed, MEDLINE, and Embase from the inception date of each database through May 30, 2017 was conducted for all articles involving meta-analyses of pharmacological or medical device knee osteoarthritis treatments compared with controls. Two reviewers independently screened articles for eligibility and extracted data for analysis. We present effect estimates on a standardized mean difference (SMD) scale and compare them all against a threshold for clinical importance of 0.50 standard deviation (SD) unit.Ten meta-analyses (sample size range, 110 to 39,814) providing a total of 19 different effect sizes for pain were included in this review. SMD estimates ranged from 0.08 to 0.79 for various electrical modalities, orthotic devices, topical and oral nonsteroidal anti-inflammatory drugs (NSAIDs), dietary supplements, and intra-articular injection therapies. Seventeen treatments demonstrated significant improvements in terms of pain when patients who had received treatment were compared with controls. After accounting for the intra-articular placebo effect, the greatest effect estimates were those of intra-articular platelet-rich plasma and high molecular weight hyaluronic acid. When these were judged according to our threshold for clinical importance, high molecular weight intra-articular hyaluronic acid was found to have the most precise effect estimate that surpassed this threshold. Platelet-rich plasma was found to provide the greatest point estimate of the treatment effect, but the precision around this estimate had the largest amount of uncertainty across all treatments.While many nonoperative treatments demonstrated significant improvements in pain, we found the greatest effect estimates for intra-articular treatments. While platelet-rich plasma provided the greatest point estimate of the treatment effect, variability among studies suggests that future research into optimal formulations is required. The strongest current evidence supports clinically important and significant treatment effects with intra-articular hyaluronic acid formulations between 1,500 and6,000 kDa.Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Dozens of national, state-based, and local quality campaigns have emerged to help hospitals reduce readmissions. The Center for Medicare and Medicaid Services (CMS) began in 2012 to financially penalize hospitals with what is now a 3% reduction in reimbursements for having higher than expected 30

Post-operative rehabilitation after staged total knee arthroplastiess (TKAs) in severely deformed bilateral knee disease can be a very difficult task. At the same time, the safety of simultaneous (one stage) bilateral TKA remains controversial and highly debatable. We wish to report our experience with simultaneous bilateral conventional TKAs for all severely deformed knees, followed by a carefully planned, evidence-based rehabilitation programme. Simultaneous bilateral TKA in severely deformed knees is safe and very effective, provided attention to details of rehabilitation and overall multidisciplinary medical care is exercised.

Prospective randomised study on the early clinical outcome of anterior midline versus anterolateral incision for total knee arthroplasty (TKA). To assess the early clinical outcome of anterior midline versus anterolateral incision for TKA in terms of wound dehiscence, time for wound healing, lateral flap numbness and knee range of movements. A total of 40 consecutive patients randomly received either anterior midline (midline group; 20 patients, 25 TKAs) or anterolateral skin incision (anterolateral group; 20 patients, 24 TKAs) followed by anteromedial arthrotomy. Postoperatively, the patients were assessed for wound dehiscence, time for wound healing, lateral flap numbness and range of movements. Midline group demonstrated more wound dehiscence, longer healing time and lateral flap numbness compared to anterolateral group. Although the incision was shorter in midline group(P

Pulmonary hypertension is clinically defined by a mean pulmonary artery (PA) pressure of 25mm Hg or more at rest, as measured by right heart catheterization. To identify patients who are likely to have a beneficial response to calcium channel blockers (CCBs) and therefore a better prognosis, acute vasodilator testing should be performed in patients in certain subsets of pulmonary arterial hypertension (PAH). A near normalization of pulmonary hemodynamics is needed before patients can be considered for therapy with CCBs. Intravenous adenosine, intravenous epoprostenol, inhaled nitric oxide, or inhaled iloprost are the standard agents used for vasoreactivity testing in patients with idiopathic PAH. In this review we describe the various aspects of vasodilator testing including the rationale, pathophysiology and agents used in the procedure.

Tako-tsubo cardiomyopathy is a relatively recently recognized clinical entity, which presents similar to an acute myocardial infarction but there is no evidence of obstructive coronary artery disease on cardiac catheterization. It mostly affects postmenopausal women and an episode of acute illness or stress can often be identified preceding the presentation. Tako-tsubo cardiomyopathy (TCM) usually has a favorable outcome and an excellent prognosis but, in rare instances, it can be associated with life threatening complications. We report a unique case of TCM where the patient presented with a transient complete heart block.

The purpose of the study was to assess whether fever in the immediate postoperative period after total knee arthroplasty was indeed related to the fall in haemoglobin. Only patients undergoing bilateral simultaneous total knee replacement were included in the study since the fall in haemoglobin is expected to be more as compared to unilateral cases. The mean fall in haemoglobin of 25 patients having immediate postoperative fever ('fever group') was compared with 27 patients having no fever ('no-fever group'). Though the mean fall of haemoglobin in 'fever group' was more compared to 'no-fever group', the difference was not statistically significant. Therefore, this study does not support the view that immediate postoperative fever after total knee arthroplasty is related to drop in haemoglobin.

IntroductionWe report the first case of prosthetic valve endocarditis caused by Gemella sanguinis.CaseA 27-year-old woman with a history of rheumatic heart disease with mechanical aortic and mitral valve replacements reported a recent toothache treated with amoxicillin, with improvement. Several day

Management of bone and joint injuries is commonly done by immobilisation using plaster/fibreglass casts. This study describes design and fabrication of patient specific cast using 3D printing. The 3D printed cast while being patient friendly is superior to earlier casts in healing efficacy and hence redefines the joint immobilisation practice. We present here a case of “walk on brace” design and fabrication using 3D printing. The custom design of ankle immobilisation cast was done for an 18-year-old boy having tibia bone fracture during gymnastic activity. The workflow comprises of anatomical data acquisition, CAD, 3D printing, post processing and clinical approval for use. Additional features such as straps, anti-slip inner surface and tread for floor grip were incorporated in the design.