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Background: The pathophysiology of Acute Pancreatitis (AP) may be complicated by endothelial activation. von Willebrand Factor (vWF)- ADAMTS13 axis is a marker of endothelial activation. The study aimed to investigate the axis in AP, comparing it in patients with and without persistent organ failure (OF), with and without pancreatic necrosis, and correlating it with the standard severity scores (CRP, APACHE II, BISAP, SOFA, and qSOFA) METHODS: vWF-Antigen (vWF:Ag), vWF-Collagen-Binding-Assay (vWF:CBA), and ADAMTS13 activity (ADAMTS13:act) levels were measured within 5 days of symptom onset in consecutive patients (n = 98), who were admitted with a first episode of AP (Dec 2021-May 2023)., Results: Of the 98 patients admitted with AP, 78(79.6 %) had no or transient OF; 20(20.4 %) had persistent OF. Age was comparable (43.73 ± 15.36 vs 38.65 ± 13.69) [mean ± SD](years), and males were predominant in both groups (70.5 % vs 80 %). Patientswith persistent OF had higher vWF:CBA(%)[323(279-486.5) vs 199.5(159.1-295.75)] and lower ADAMTS13:act(%)[35.4(23.8-56.85) vs 56.35(44.1-71.9)][median (25th - 75th percentile)](P = 0.001) than those with no or transient OF. Patients with pancreatic necrosis (n = 19) had lower ADAMTS13:act(%)[42.79 ± 18.69] than those without pancreatic necrosis (n = 18) [62.49 ± 22.64] (P < 0.01). ADAMTS13:act had a negative correlation(r = -0.2), whereas vWF:Ag and vWF:CBA had a positive correlation (r = 0.2) with the standard severity scores (P < 0.05). ADAMTS13:act could predict pancreatic necrosis [AUROC-0.737, P < 0.05] and persistent OF [AUROC-0.746, P < 0.001], while vWF:CBA could predict persistent OF [AUROC- 0.73, P < 0.001]., Conclusion: vWF-ADAMTS13 axis helps to predict severe disease and is associated with poor outcomes in acute pancreatitis., (Copyright © 2024 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background: Ultrasound-guided (USG) erector-spinae plane block (ESPB) may be better than intravenous opioids in treating acute hepatopancreaticobiliary (HPB) pain in the ED., Methods: This open-label randomised controlled trial was conducted in the ED of a tertiary-care hospital between March and August 2023. All adult patients with severe HPB pain were recruited during times that a primary investigator was present. Unconsenting patients, numeric rating scale (NRS) ≤6, age ≤18 and ≥80 years, pregnant, unstable or with allergies to local anaesthetics or opioids were excluded. Patients in the intervention arm received bilateral USG ESPB with 0.2% ropivacaine at T7 level, by a trained ED consultant, and those in the control arm received 0.1 mg/kg intravenous morphine. Pain on a 10-point NRS was assessed by the investigators at presentation and at 1, 3, 5 and 10 hours after intervention by the treatment team, along with rescue analgesia requirements and patient satisfaction. Difference in NRS was analysed using analysis of co-variance (ANCOVA) and t-tests., Results: 70 participants were enrolled, 35 in each arm. Mean age was 40.4±13.2 years, mean NRS at presentation in the intervention arm was 8.0±0.9 and 7.6±0.6 in the control arm. NRS at 1 hour was significantly lower in the ESPB group (ANCOVA p<0.001). At 1, 3, 5 and 10 hours, reduction of NRS in the intervention arm (7±1.6, 6.7±1.9, 6.6±1.8, 6.1±1.9) was significantly greater than the control arm (4.4±2, 4.6±1.8, 3.7±2.2, 3.8±1.8) (t-test, p<0.001). Fewer patients receiving ESPB required rescue analgesia at 5 (t-test, p=0.031) and 10 hours (t-test, p=0.04). More patients were 'very satisfied' with ESPB compared with receiving only morphine at each time period (p<0.001)., Conclusion: ESPB is a promising alternative to morphine in those with HPB pain., Trial Registration Number: CTRI/2023/03/050595., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To retrospectively describe the clinicopathological profile and treatment outcome of sex cord ovarian tumours (SCOTs), from a single institution., Methods: Patients who operated for SCOT between January 2011 and December 2020 were identified from the institution's discharge summaries. Treatment details and oncologic outcomes were analyzed using descriptive statistics, SPSS statistics version 21. Progression-free survival and overall survival were plotted using the Kaplan-Meier method., Results: Over 10 years, 120 patients underwent surgery with 73 (61%) malignant SCOTs. Eight (6.6%) were referred with recurrence. Granulosa cell histology (61/73, 83.5%) and federation of gynaecology and obstetrics (FIGO) stage I disease (57/65, 78.62%) were predominant. Three (3/26,11.53%) had lymph node involvement. Adjuvant chemotherapy was advised in 53.4% (39/73).Over a median period of 47 months (1-130 months), eleven (15.06%) patients recurred (5-year recurrence rate: 9.58%) and 6 died (5-year survival rate: 89.04%).Among 65 patients with upfront disease, 9 (13.8%) recurred over a median period of 46 months (1-65 months) with 4 disease-related deaths. On univariate analysis, incomplete cytoreduction hazard ratios (HR 58.391, 95% CI 5.042-674.854), advanced FIGO stage (HR 15.931, 3.74-67.89) and nongranulosa histology was associated with recurrence. On multivariate analysis, advanced FIGO stage (HR 20.099, 95% CI 3.75-107.711) and non granulosa histology (HR 31.35, 95% 2.801-350.897 ) remained significant. Lymphadenectomy and adjuvant chemotherapy did not prevent recurrence., Competing Interests: The authors have no conflict of interest to declare., (© the authors; licensee ecancermedicalscience.)

Background: Epidural opioids provide effective postoperative analgesia after lumbar spine surgery. Ketamine has been shown to reduce opioid-induced central sensitization and hyperalgesia. We hypothesized that adding ketamine to epidural opioids would prolong the duration of analgesia and enhance analgesic efficacy after lumbar spine surgery., Methods: American Society of Anesthesiologists physical status class I to II patients aged between 18 and 70 years with normal renal function undergoing lumbar laminectomy were recruited into this single-center randomized trial. Patients were randomized to receive either single-dose epidural morphine (group A) or epidural morphine and ketamine (group B) for postoperative analgesia. The primary objective was to compare the duration of analgesia as measured by time to the first postoperative analgesic request. Secondary objectives were the comparison of pain scores at rest and movement, systemic hemodynamics, and the incidence of side effects during the first 24 hours after surgery., Results: Fifty patients were recruited (25 in each group), of which data from 48 were available for analysis. The mean±SD duration of analgesia was 20±6 and 23±3 hours in group A and group B, respectively ( P =0.07). There were 12/24 (50%) patients in group A and 17/24 (71%) patients in group B who did not receive rescue analgesia during the first 24-hour postoperative period ( P =0.07). Pain scores at rest and movement, systemic hemodynamics, and postoperative complications were comparable between the groups., Conclusions: The addition of ketamine to epidural morphine did not prolong the duration of analgesia after lumbar laminectomy., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Low-volume plasma exchange (PLEX) and low-dose steroid improve survival in severe alcoholic hepatitis. We aimed to compare one-year survival of very severe alcoholic hepatitis (VSAH) patients treated with centrifugal PLEX (cPLEX), membrane PLEX (mPLEX) or standard medical treatment (SMT)., Methods: We retrospectively analyzed survival in consecutive VSAH patients treated at our department from November 2017 to September 2021. PLEX patients received low-volume PLEX along with low-dose steroid (tab. prednisolone 10 mg or 20 mg daily). To adjust for baseline differences between the three treatment (cPLEX, mPLEX or SMT) groups, propensity score (PS) matching was done. Acute-on-chronic liver failure (ACLF) was defined as per European Association for the Study of the Liver (EASL). The primary study outcome was one-year transplant-free survival of PS-matched VSAH patients treated with cPLEX compared to SMT., Results: Of 101 PLEX-eligible VSAH patients, 30 patients were treated with cPLEX, 21 with mPLEX and 50 with SMT. On comparing 30 PS-matched patients each in the cPLEX group vs. the SMT group, transplant-free survival in the cPLEX group was 86.7% at one month, 70% at three months and 52.4% at one year and in the SMT group was 33.3% at one month, 23.3% at three months and 16.7% at one year with hazard ratio (HR [95% CI]) in favor of the cPLEX group (0.29 [0.15-0.56], p < 0.001). Total 21 patients each (PS-matched) in cPLEX and mPLEX groups were compared and one-year survival was better with cPLEX (0.33 [0.16-0.69], p = 0.001). The sub-group analysis of VSAH (PS-matched cohort) patients with ACLF also showed better survival with cPLEX compared to SMT (0.38 [0.17-0.83], p = 0.003) and compared to mPLEX (0.43 [0.17-0.95], p = 0.03)., Conclusion: Better one-year transplant-free survival was noted among PS-matched VSAH patients treated with cPLEX (and low-dose steroid) compared to SMT (without steroid)., (© 2024. Indian Society of Gastroenterology.)

Objective: To evaluate the efficacy of antenatal corticosteroids in reducing neonatal respiratory complications when administered to those at risk of preterm delivery between 34 and 36 6/7 weeks of gestation., Methods: This was a single-center, triple-blind, randomized, placebo-controlled trial in southern India enrolling pregnant participants at risk of preterm delivery between 34 and 36 6/7 weeks of gestation. Computer-generated block randomization was used with participants randomized to either one course of intramuscular betamethasone or placebo. The primary outcome was a composite of treatment for respiratory distress in the neonate, defined as need for oxygen or continuous positive airway pressure or mechanical ventilation for at least 2 hours in the first 72 hours of life. Neonatal secondary outcomes were transient tachypnea of the newborn, respiratory distress syndrome, necrotizing enterocolitis, sepsis, hyperbilirubinemia, hypoglycemia, stillbirth, and early neonatal death; maternal secondary outcomes were chorioamnionitis, postpartum hemorrhage, puerperal fever, and length of hospitalization. All analyses were based on intention to treat. A sample size of 1,200 was planned with 80% power to detect a 30% reduction in rates of respiratory distress. After a planned interim analysis, enrollment was stopped for futility., Results: From March 2020 to August 2022, 847 participants were recruited, with 423 participants randomized to betamethasone and 424 participants randomized to placebo. There were 22 individuals lost to follow-up. There was no statistically significant difference in the primary outcome (betamethasone 4.9% vs placebo 4.8%, relative risk 1.03, 95% CI, 0.57-1.84, number needed to treat 786). There were no statistically significant differences in secondary neonatal or maternal outcomes., Conclusion: Betamethasone administered in the late-preterm period to those at risk for preterm delivery did not reduce the need for treatment of neonatal respiratory distress., Clinical Trial Registration: Clinical Trials Registry of India, CTRI/2019/09/021321., Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest., (Copyright © 2024 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Fibrosis is a typical pathological characteristic in IgG4-RD patients and often irreversible. There exists a lack of suitable markers for detection of earlier onset of fibrosis in various organs in IgG4-RD patients. Hence, this study aims at analysing ambispectively the myofibroblasts and the pro-fibrotic cytokines, IFN gamma and IL-33 involved in IgG4-RD associated fibrosis in South Asian patients., Method: Archived biopsy samples of definite/probable/possible cases of IgG4-RD, classified according to diagnostic criteria, taken from patients who attended the OPD and IPD of our tertiary care centre during January 2015-January 2020 were chosen for this study. The paraffin sections were examined qualitatively for fibrosis and the excessive collagen deposition by Hematoxylin & Eosin and Masson's Trichrome staining. Also, the presence of alpha-Smooth muscle actin (α-SMA) expressing myofibroblasts and the involvement of pro-fibrotic cytokines (IFN-gamma, IL-33) were assessed by Immunohistochemistry and scored semi-quantitatively (+mild, ++moderate, +++ severe). Serum IL-33 levels were analysed by indirect Elisa (R & D Systems)., Results: Myofibroblasts were present in 10/12 biopsy samples, in moderate levels in 4 (33%) and very high levels (+++) in 3 (25%) of the patients. IFN-gamma was expressed at low levels in 6 (50%) and absent in 6 (50%). All patients showed IL-33 expression with very high levels in tissue (6, 50%), as well as in serum samples., Conclusion: The findings of this study reinforce the role of myofibroblasts and profibrotic cytokines like IL-33 in fibrosis of Ig4-RD patients, pointing to their potential as earlier predictive markers of onset and extent of fibrosis., (© 2024. The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR).)

Objectives: To assess the effectiveness of using mustard seed filled pillows in preventing deformational plagiocephaly (DP) in premature infants., Methods: A prospective open label randomized trial was conducted in a tertiary care hospital in South India. Eligible preterm infants born at ≤32 weeks and <1500 g admitted in the neonatal intensive care unit (NICU) were randomly allocated to the intervention and control groups. In addition to standard nesting, the intervention group was positioned using a mustard pillow, while the control group was positioned using nesting alone. Plagiocephaly was assessed using the Cranial Index (CI), Cranial Vault Asymmetry Index (CVAI) and Argenta classification within the first week and at 4 weeks postnatal age., Results: Twenty-eight infants, each in the control and intervention groups, were included for analysis. At 4 weeks postnatal age, the intervention group had lower mean (SD) CVAI scores when compared to the control group [3.16 (1.89 vs 7.85 (2.63)] with adjusted odds ratio, aOR (95% CI) of 28.2 (3.8, 210.01), P < 0.01. More number of infants in the control group had plagiocephaly measured using Argenta classification [aOR (95% CI) 25.70 (2.80, 235.67), P < 0.01]. There were no differences in the Cranial Index scores in the intervention and control groups [aOR (95% CI) 0.41 (0.11, 1.52), P = 0.184]., Conclusion: A mustard seed pillow is an easily available and a cost-effective intervention for preventing plagiocephaly in hospitalized preterm infants.

We aimed to compare the demography, clinical profile, histopathology, fungal culture, radiology, surgery performed, medical therapy and outcomes of patients with acute invasive fungal sinusitis seen during the first and second waves of the COVID-19 pandemic by retrospectively reviewing their case records. Of 238 patients, 43(18.1%) presented during the first wave and 195(81.9%) during the second wave. Patients seen during the first wave were older (p = 0.04) and more likely to have visual impairment (p = 0.004), frozen eye (p = 0.012), altered sensorium (p = 0.007) and stage 3 disease (p = 0.03). Those seen during the second wave were more often COVID-19 positive and had newly diagnosed diabetes mellitus (p = 0.04)and stage 1 disease (p = 0.03). Most patients had a positive culture for Rhizopus species during both waves. Histopathology showed broad aseptate hyphae in all patients but angioinvasion was seen more often during the first wave (p = 0.04). The majority of patients were treated with endoscopic+/- open debridement followed by intravenous amphotericin B and oral posaconazole. While the overall survival rate was similar (first wave 65.1%; second wave 79%; p = 0.106), mortality after discharge was greater during the first wave (11.6% vs 1.5%; p = 0.001). Mortality was higher in patients with stage 3 disease (p = 0.003). Significant differences in clinical presentation, histopathology, radiological stage of disease and post-discharge survival were noted between the two waves of the COVID-19 pandemic, the causes for which were multi-factorial., Competing Interests: Conflict of interestThere is no conflict of interest for any of the authors listed above., (© Association of Otolaryngologists of India 2023. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Prospective and sequential evaluation of homeostatic changes leading to thrombosis across COVID 19 disease severity spectrum are limited. In this prospective observational study, haemostasis was evaluated in patients with mild, moderate-severe, and critical COVID-19 infection. Markers of endothelial activation [Soluble thrombomodulin (sTM), von Willebrand Factor (VWF)], platelet activation [Soluble P-selectin, beta-thromboglobulin (BTG)] and global haemostasis [Rotational thromboelastometry (ROTEM)] were evaluated on days 1 and 5 after admission. The study cohort comprised of 100 adult patients (mild = 20, moderate-severe = 22, critical = 58). Sixty-five patients received anticoagulation for 10 (7-14) days. Thrombotic events were seen in 9 patients. In-hospital mortality was 21%. Endothelial activation markers were elevated at baseline in all subgroups, with levels in moderate-severe (sTM = 4.92 ng/ml, VWF = 295 U/dl) [reference-ranges: sTM = 2.26-4.55 ng/ml; Soluble P-selectin = 13.5-31.5 ng/ml; BTG = 0.034-1.99 ng/ml] and critical patients (sTM = 6.07 ng/ml, VWF = 294 U/dl) being significantly higher than in the mild group (sTM = 4.18 ng/ml, VWF = 206 U/dl). In contrast, platelet activation markers were elevated only in critically ill patients at baseline (Soluble P-selectin = 37.3 ng/ml, BTG = 2.51 ng/ml). The critical group had significantly lower fibrinolysis on days 1 and 5 when compared with the moderate-severe arm. COVID-19 infection was associated with graded endothelial activation and lower fibrinolysis that correlated with illness severity., (© 2024. The Author(s).)

Aim: Diabetic patients are prone to infections, thus making them a unique cohort at risk of developing bacterial infection-related glomerulonephritis (IRGN)., Methods: In total, 1693 adult diabetic patients underwent kidney biopsy between 2005 and 2021 at our tertiary care hospital in South India. Of these, 121 consecutive cases which met criteria of bacterial IRGN were included in this study., Results: The mean age of the cohort was 53.1 ± 10.1 years and 83/121 (68.5%) were males. Majority (98.3%) had type 2 diabetes for a median duration of 6 (IQR, 2-12) years. The most common sites of infection were skin (47/121, 38.8%) and urinary tract (15/121, 12.4%). Fifty percent (58/121) of patients had underlying advanced diabetic kidney disease (DKD). Isolated C3 deposits (without immunoglobulin) occurred in 66/121 (54.5%) patients predominantly in advanced DKD patients. IgA-dominant glomerulonephritis occurred in only 9/121 (7.4%) patients. Short-course oral steroid was given to 86/121 (71.1%) patients. Steroid related dysglycemia and immunosuppression related infections occurred in 9/61 (14.8%) and 16/61 (26.2%) patients respectively. Of the 90 patients with follow up details >3 months, 46 (51.1%) progressed to kidney failure over a median period of 0.5 (IQR, 0-7.2) months. Patients diagnosed in the latter half of our study period (2013-2021) were older, less commonly presented with fever, had more pronounced hypocomplementemia and severe renal histology predominantly with a 'starry sky' immunofluorescence pattern., Conclusion: Superimposed bacterial IRGN on underlying DKD is associated with poor renal outcomes. Use of short course steroid was associated with significant toxicity., (© 2023 Asian Pacific Society of Nephrology.)

Jeyashanth Riju Objectives  The study was aimed to (1) evaluate the effectiveness of clinical examination, intraoperative finding, and contrast-enhanced computed tomography (CECT) to detect extranodal extension (ENE) in buccoalveolar complex squamous cell carcinoma (BAOSCC), (2) to know various factors influencing ENE, and (3) to evaluate survival outcome in patients with ENE. Materials and Methods  This was a retrospective cohort study, which included 137 patients with BAOSCC who underwent curative treatment between May 2019 and April 2021. Collaborative findings suggestive of ENE were noted during preoperative clinical examination, CECT, and intraoperatively, and their efficacy was compared with postoperative histopathology. Also, the various factors associated with ENE were evaluated and compared. Statistical Analysis  Univariate and multivariate analysis of parameters was done using multiple logistic regression analysis and significant correlation was determined using chi-square test between ENE positive and negative categories. Analysis of prognosis and survival was done by Kaplan-Meier curve plotting using regression analysis and its significance was compared. Results  The overall prevalence of ENE was 18.98% and that of lymph node involvement was 40.88%. CECT (73.1%) was found to be more sensitive in detecting ENE compared to intraoperative examination (46.2%) and clinical examination (34.6%).In comparison with clinical examination (91.9%) or CECT (78.38%), intraoperative examination (93.7%) showed the highest specificity in detecting ENE. Clinical nodal size ≥ 3 cm ( p ≤ 0.001), fixity ( p ≤ 0.001), and clinical number of nodes ( p ≤ 0.001) had significant association with ENE. The presence of thick nodal walls on CECT increased the probability of predicting ENE 15 times ( p  = 0.180, confidence interval: 0.3-765.4). After a mean follow-up of 18 months, subjects without nodal positivity had a survival advantage over patients with positive lymph nodes (86.4% vs. 53.3%) and those with ENE (86.4% vs. 23.2%), respectively. Conclusion  The results demonstrated that clinical examination can be used as an adjuvant to radiological imaging for prediction of ENE preoperatively. Clinical finding suggesting size of node ≥ 3 cm and ≥ 2 nodes are strong predictor of ENE, in addition to other known predictors. Patients with ENE had an unfavorable prognosis when compared with subjects with metastatic nodes without ENE. Presence of ENE remains one of the strongest factors predicting recurrence and thus poor prognosis., Competing Interests: Conflict of Interest None declared., (MedIntel Services Pvt Ltd. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Objective: We planned a study to evaluate the impact of selecting hysterosalpingography (HSG) over diagnostic laparoscopy during initial fertility evaluation on IUI treatment outcomes in couples diagnosed with unexplained infertility., Methods: The study comprised a retrospective cohort and included couples evaluated for infertility at our tertiary level hospital between January 2008 and December 2019. Couples diagnosed with unexplained infertility based on tubal patency tests (either HSG or diagnostic laparoscopy) were included. We compared outcomes following ovarian stimulation (OS) and intrauterine insemination (IUI) between women who underwent HSG versus laparoscopy for up to three treatment cycles., Results: A total of 7413 women were screened, out of which 1002 women were diagnosed with unexplained infertility. We did not find a significant statistical difference in the clinical pregnancy (16.7% vs. 11.7%; OR (odds ratio) 1.51; 95% CI (confidence interval) 0.90-2.5) or live birth rate per IUI cycle (15.1% vs. 10.7%; OR 1.51, 95% CI 0.9-2.6) in women who underwent HSG for tubal evaluation as compared to laparoscopy. After adjustment for potential confounders through multivariate analysis, we found that outcomes were comparable between the HSG and laparoscopy., Conclusion: The current study did not find any significant difference in treatment outcomes following OS and IUI in women with unexplained infertility who underwent HSG compared to laparoscopy for the assessment of the tubal patency during the initial fertility workup. The finding suggests minimal or no impact of selecting HSG over diagnostic laparoscopy as a tubal patency test on the subsequent IUI outcomes., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: While elective single-embryo transfer (eSET) has been advocated in select countries, the global acceptance of the eSET policy has been undermined due to various issues. It is imperative to understand the couples' perspectives regarding the number of embryos transferred., Aims: We planned a study to evaluate the knowledge and attitude of infertile couples undergoing assisted reproductive technology towards eSET in self-funded treatment cycles in a low-resource setting., Settings and Design: We conducted a cross-sectional study at a tertiary-level referral facility between February 2020 and September 2022., Materials and Methods: This was an interviewer-administered questionnaire-based survey in two stages. The first stage involved the assessment of the knowledge of the participants. Following this, participants were given an information pamphlet and the second stage of the interview was conducted to assess the attitude and change in preference for embryo transfer number., Statistical Analysis Used: The Chi-square and Fisher's exact test were applied to find an association between categorical variables. Logistic regression was used to assess the association between factors and outcomes., Results: eSET was the preferred choice for only 5.8% of the participants. Following our educational intervention using an information leaflet, there was a statistically significant increase in the preference for eSET ( P = 0.01). Univariate logistic regression analysis revealed that participants with a monthly income of ≤50,000 INR had a significantly higher preference for eSET., Conclusion: Continued emphasis on the risks of double-embryo transfer coupled with individualised selection criteria for eSET may help to achieve reasonable congruency between the clinician and couples' decision., Competing Interests: Dr. Mohan Shashikant Kamath is the Associate Editor of JHRS. He has had no role in peer-review process or editorial decisions., (Copyright: © 2023 Journal of Human Reproductive Sciences.)

Objectives: This study aimed to assess sexual health and quality of life (QoL) in endometrial cancer survivors and the factors influencing these variables., Methods: A mixed method design comprising quantitative (cohort design) and qualitative (face-to-face interviews) aspects was chosen. A total of 132 patients who underwent surgery alone, surgery followed by adjuvant vaginal brachytherapy, or surgery followed by chemotherapy and radiation were included. Female Sexual Function Index (FSFI) and Functional Assessment of Cancer Therapy General (FACT-G) questionnaires were used to assess the participants' sexual health and QoL at 6 months and 1 year post-treatment. Multivariate logistic regression models were used to analyze the factors associated with general and sexual well-being., Results: At 1 year, 89% of the participants still had low sexual function scores. Survivors over 50 years (OR 284.7, 95% CI 13 to 364, p<0.001) and educated below graduate level (OR 26.8, 95% CI 2 to 370, p=0.014) had low sexual function scores. Patients who had surgery alone had better QoL than those who received adjuvant radiation. Women who had surgery, chemotherapy, and radiation had the lowest QoL scores (OR 6.4, 95% CI 2.1 to 19.5, p=0.001). All scores improved with time., Conclusions: This study demonstrated the high prevalence of low sexual function and poor QoL in endometrial cancer survivors. There was a communication gap between the women and their partners as well as their healthcare providers. This study highlights the need for discussion about the survivors' sexual well-being and QoL., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Lateral Hoffa nonunion are rare injuries. A significant percentage of these nonunions are due to missed acute lateral Hoffa fractures. Operative management of these injuries is difficult and complicated by the presence of bone loss, infection, and soft-tissue contractures. In this study, the aim was to assess clinical and functional outcome in our group of patients with lateral Hoffa nonunion who had undergone operative management and to determine whether variables such as fracture type, infection, and previous surgery affect nonunion/complication rates., Materials and Methods: Data were analyzed for patients with lateral Hoffa nonunion who underwent surgical fixation from January 2008 to December 2020 at a tertiary-care referral center. Patients with lateral condyle Hoffa nonunion and having a minimal follow-up of 1 year were included in this study. Patients with medial Hoffa nonunion, pathological fractures, and children aged less than 16 years were excluded from the study. The fractures were classified by the AO/OTA and Letenneur classification systems. Clinical and functional outcomes were assessed by the Knee society score (KSS) and the lower extremity functional scale (LEFS)., Results: All the 12 patients had united in our series. One patient had reduction failure at 3 months who united after re-fixation. The union rate in our patients was 100%, with a loss of reduction rate of 7.7%, and post-traumatic arthrosis of 7.7%. The average follow-up period was 52.16 ± 27.7 months. The mean knee flexion obtained at the final follow-up was 104.5° (80°-130°). The average KSS clinical score was 80.6 (65-88). The average KSS functional score was 92 (70-100). The average LEFS score was 71 (47-79). There is a statistically significant improvement in the knee range of motion in our patients (p = 0.001). However, no correlation could be detected between variables like type of fracture, infection, and previous surgeries and outcomes., Conclusions: Lateral Hoffa nonunion can be managed with careful planning of surgical approaches and fixation techniques., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Mansi AgrawalVidya Konduru Background  Oral cavity cancers require definitive surgical resection as the primary treatment, but with advanced T stage, complete resection with pathologically negative margins might be difficult to achieve. Induction chemotherapy helps achieve the balance between resection and morbidity in locally advanced technically unresectable tumors. The aim of this study was to analyze the impact of surgery in locally advanced, technically unresectable oral cavity cancers after neoadjuvant chemotherapy (NACT). Materials and Methods  A retrospective analysis of patients with borderline resectable, locally advanced oral cavity cancers who were given NACT between February 2017 and December 2021 was conducted. Data regarding clinical and pathological characteristics, NACT, surgery, adjuvant therapy, and recurrences was analyzed. Results  Of the 69 patients in the study, 69.6% had tongue cancer, rest were gingivobuccal complex cancers. All tumors were resected based on the post-NACT tumor volume and clear margins were achieved in 42% of cases. About 85.4% of the tongue cancers required a lesser resection than anticipated, thereby following the concept of organ and functional preservation post-NACT as proposed by Licitra et al. About 30.4% had ypT0 and 17.4% had ypN0. Recurrence and survival rates noted in our study were comparable to those reported in literature. Lymph node density of more than or equal to 0.07 was found in all recurrent cases. Conclusions  Induction chemotherapy offers a chance of achieving adequate surgical resection while reducing morbidity and improving functional outcomes for patients with technically unresectable oral cavity cancers. Nodal disease may not respond to chemotherapy as well as the primary tumor. There is a need for comprehensive evaluation of prognostic factors, which could help identify the patients who will most benefit with NACT., Competing Interests: Conflicts of Interest None declared., (MedIntel Services Pvt Ltd. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: Patients with cervical/upper thoracic compressive myelopathy may have autonomic dysfunction. The composite autonomic severity score (CASS) is the gold standard test to detect autonomic dysfunction, and the self-rated composite autonomic system scale (COMPASS-31) questionnaire is a screening tool to diagnose autonomic dysfunction. This study compared the COMPASS-31 and modified CASS scores for the detection of autonomic dysfunction in patients with compressive myelopathy., Methods: Patients with cervical/upper thoracic compressive myelopathy scheduled for decompressive surgery completed a COMPASS-31 questionnaire and underwent autonomic function tests to calculate the modified CASS score before surgery., Results: Forty-two patients were included in the study; 19 (45.2%) had mild autonomic dysfunction, 5 (11.9%) had moderate autonomic dysfunction, and 18 (42.9%) had severe autonomic dysfunction. Median (interquartile range) of modified CASS and COMPASS-31 scores were 19 (6.33) and 3 (2.5), respectively. There was a positive correlation between modified CASS and COMPASS-31 scores ( r =0.43; P =0.004). Receiver operating characteristic curve analysis confirmed that COMPASS-31 had fair accuracy for prediction of moderate to severe autonomic dysfunction (area under the curve, 0.74; 95% confidence interval, 0.64-0.82; P =0.009). A cut-off of 30 for total COMPASS-31 score had a sensitivity of 52.2% and specificity of 89.5% to detect moderate to severe autonomic dysfunction, with positive and negative predictive values of 85.7% and 60.7%, respectively., Conclusion: Patients with cervical/upper thoracic compressive myelopathy had varying degrees of autonomic dysfunction based on the modified CASS. There was a positive correlation between the modified CASS and COMPASS-31 questionnaire. A COMPASS-31 score of >30 30 could be utilized to predict moderate to severe autonomic dysfunction in patients with compressive myelopathy., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: This study aims to investigate the use of the neutral comet assay to assess deoxyribonucleic acid (DNA) damage in lymphocytes exposed to high doses of radiation., Materials and Methods: The research was conducted by obtaining informed consent, after which blood samples were taken from seven healthy individuals and this study was approved by the institutional ethics committee. At first, for the determination of dose-effect curves, samples obtained from the first five individuals were irradiated for doses ranging from 0 to 35 Gy after which they were processed under neutral comet assay. In order to verify the determined dose-effect curves, a test dose of 15 Gy was delivered to the samples obtained from the sixth and seventh individuals. The amount of DNA damage from the obtained comet assay images was analyzed using four comet assay parameters namely % tail DNA, tail length, tail moment (TM), and Olive TM (OTM). The most suitable comet assay parameter was evaluated based on the obtained dose-effect curves. Furthermore, the distribution of individual cells for each dose point was evaluated for all the four comet assay parameters to find the optimal parameter., Results: From our results, it was found that from 0 to 25 Gy all the four comet assay parameters fit well into a linear quadratic curve and above 25 Gy saturation was observed. Based on the individual cell distribution data, it was found that % tail DNA could be an optimal choice to evaluate DNA damage while using neutral comet assay for high-dose ionizing radiation., Conclusion: The neutral comet assay could be a potential tool to assess DNA damage from high doses of ionizing radiation greater than 5 Gy., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Medical Physics.)

Introduction: Post hematopoietic stem cell transplant (HSCT), kidney can be subjected to injury by various causes. Of these, graft versus host disease (GvHD) affecting the kidney is an under-recognized entity with no clear guidelines on its diagnosis, clinicopathological manifestations, and outcomes., Material and Methods: Out of 2,930 patients who underwent HSCT at our center between 2005 and 2020, kidney biopsy was performed in 19 allogenic and 5 autologous recipients., Results: The mean age of the cohort at transplant was 33.2 ± 7 years, and 15 (62%) were males. Median time to kidney biopsy from HSCT was 14 (IQR, 9-30) months. Aplastic anemia was the most common underlying hematological disease (54.2%). All 19 allogenic recipients were classified based on clinicopathological manifestations into either thrombotic microangiopathy (TMA, 12/19 [63%]) or nephrotic syndrome (NS, 7/19 [37%]) pattern. Glomerular tuft "mesangiolysis" was the dominant pattern of injury noted in 9/12 cases of TMA pattern. There was a predominance of acute microangiopathic changes restricted primarily to the glomerular compartment. Of the 7 patients with NS pattern, membranous nephropathy was seen in 4 (57%) and minimal change disease in 3 (43%) patients. Thirty-nine percent (7/18) stained positive for C4d which was predominantly glomerular. Allogenic recipients who did not receive immunosuppression (IS) for renal disease had a lower eGFR at biopsy, a longer latency between withdrawal of GvHD prophylaxis and biopsy, and were significantly at a higher risk of kidney failure (IS: 2/11, 18.1% vs. no IS: 2/6, 33.3%, p = 0.04). "Associated extra-renal GvHD" occurred in 11/19 (57.9%) allogenic recipients. Patients with "associated extra-renal GvHD" had significantly more deaths (6/11, 60% vs. 0, p = 0.02) but comparable renal outcomes., Conclusion: Renal GvHD can present with or without "associated extra-renal GvHD" after a prolonged period of withdrawal of GvHD prophylaxis, requiring careful diagnostic vigilance and consideration of IS., Competing Interests: S. Varughese reports serving on the Kidney Medicine Editorial Board, the Indian Society of Nephrology Editorial Board, and the Indian Society of Organ Transplantation Editorial Board. All other remaining authors have nothing to disclose., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Background: Rhino-orbito-cerebral-mucormycosis (ROCM), a rare and potentially fatal disease was seen in increasing numbers during the COVID-19 pandemic. This study describes and compares the patient characteristics and outcomes in COVID-19 associated mucormycosis (CAM) and non-COVID-19 mucormycosis (non-CAM)., Methodology: CAM patients (24 cases) were recruited from the COVID-19 period and non-CAM (24 controls) from the pre-COVID-19 period. Clinical data of the CAM group was collected retrospectively with 3 month outcomes prospectively. The non-CAM group data was collected retrospectively. Patient characteristics were compared and risk factors for mortality in ROCM were assessed., Results: Orbital symptoms [altered vision, restricted eye movements, ptosis] and intracranial involvement were higher in CAM patients on presentation. Similarly, the radiological involvement of orbit (orbital apex, superior orbital fissure) and intracranial cavity (intracranial thrombosis, cavernous sinus) was also higher in CAM patients. Newly detected diabetes was found only in CAM patients (29.2%). Although univariate analysis suggested an increased mortality risk in ROCM patients with orbital involvement, the multivariate analysis showed no increased risk with any of the parameters assessed, including COVID-19 positivity., Conclusions: Compared to the non-CAM, the disease presentation was severe in CAM with higher frequency of orbital and intracranial involvement. However, with early detection and treatment, the short term survival was comparable in both groups.

Objective: To determine the demographic, aetiopathological and diagnostic profiles of patients presenting with hoarseness to a laryngology unit of a tertiary care centre in India., Methods: A retrospective observational study was conducted., Results: The 1033 patients who presented with dysphonia showed a male predominance (70 per cent), high rates of malignancy (18 per cent), late presentation (mean, 24 months) and poor follow-up trends (53 per cent with 3 months' follow up), which contrasts with data from developed countries. The patient population hailed from different states in India and neighbouring countries around India, serving as a good sample for the subcontinent. The majority (67 per cent) were managed conservatively; however, surgical management was the preferred choice for those who presented with airway stenosis (91 per cent) and laryngeal trauma (75 per cent). Significant associations between vocal professionalism level and co-morbidities and dysphonia aetiopathologies are discussed., Conclusion: These findings give insight into the trends of hoarseness in the developing Indian subcontinent, which can aid understanding and management.

Background: The second wave of the coronavirus disease 2019 (COVID-19) pandemic resulted in a significant rise in the number of infections and deaths as compared to the first wave. The published literature till now is limited to tertiary hospitals. We did this study to describe the demographic characteristics and outcomes of patients admitted to a secondary care hospital in central India during the second wave of the pandemic., Methods: This was a single-center, retrospective observational study conducted in a secondary hospital in central India. The data of patients with COVID-19 infection admitted between March 25 to May 25, 2021, were retrieved and analyzed., Results: A total of 184 patients were included in the study. The mean age was 54.8 ± 14.5 years. Comorbidities included hypertension (40.2%), diabetes mellitus (29.9%), hypothyroidism (4.3%), and asthma (2.7%). The most common presenting complaints were cough (78.8%), breathlessness (61.4%), and fever (60.9%). The mean duration of symptoms was 5.4 ± 2.6 days. According to High-Resolution Computerised Tomography (HRCT) chest severity score, 29/181 (16%) patients had mild disease, 135/181 (74.5%) patients had moderate disease, and 17/181 (9.5%) patients had severe disease. The majority of the patients received remdesivir (90.2%) and 123 patients (66.8%) received corticosteroids. Half the patients (52.2%; n = 96) required intensive care unit admission, 79.3% (145 patients) required oxygen support, and 8.1% (15 patients) required non-invasive ventilator support., Conclusion: Our study from a secondary hospital setup showed that the second wave was very severe with a high requirement of oxygen support and intensive care monitoring., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Family Medicine and Primary Care.)

Background and Aims: Substitutional urethroplasty with buccal mucosal grafting for urethral stricture is associated with significant pain, and thus inappropriate perioperative pain management could delay postoperative recovery. The objective of our research was to determine the effects of analgesia with systemic or epidural or intrathecal morphine on quality of recovery (QoR) in patients undergoing substitutional urethroplasty with buccal mucosal grafting., Material and Methods: This prospective, double-blinded, randomized control trial was conducted over 2 years in ASA I and II patients who underwent substitutional urethroplasty with buccal mucosal graft. Patients were randomized into three groups, and Group A received systemic morphine (0.1 mg/kg), Group B received epidural morphine (3 mg), and Group C received intrathecal morphine (150 μg). The QoR between the groups were compared postoperatively using the 40-item QoR questionnaire, and the hemodynamic variations, time taken for ambulation, resumption of oral intake, and incidence of complications were also compared., Results: Out of the recruited 93 patients, 88 patients were analyzed. The QoR score for each domain was comparable between the three groups. The total QoR score for systemic, epidural, and intrathecal morphine groups were 189 (185-191), 189 (187-191), and 185 (183-189), respectively. Additionally, the hemodynamic variations, time taken for ambulation, and resumption of oral intake were comparable between all three groups except the incidence of postoperative nausea and vomiting (PONV) and pruritis, which were higher in the intrathecal group., Conclusion: All three modalities, namely systemic morphine (0.1 mg/kg), epidural morphine (3 mg), and intrathecal morphine (150 μg), offer similar QoR after substitutional urethroplasty. However, the incidence of PONV and pruritis was higher with the administration of intrathecal morphine., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Anaesthesiology Clinical Pharmacology.)

Background: This study determines the diagnostic utility of lung ultrasonography (LUS) in a medical ward in a developing country. In a low resource country like India, we hope that use of lung ultrasound in primary and secondary hospitals will assist in earlier and better bedside diagnosis., Methods: This prospective diagnostic study was done to test the diagnostic accuracy of LUS against a composite reference standard, which included clinical history and examination, basic laboratory investigations, imaging and the diagnosis at discharge. We evaluated 321 consecutive patients, admitted in our medical wards with an LUS within 24 hours of the chest radiograph being done., Findings: Between August 2016 and August 2017, we enrolled 321 patients. The sensitivity and specificity of the LUS for all pathologies were found to be 82.5% (76.50 to 87.20) and 78.2% (69.09 to 85.26) respectively. A subgroup analysis including the patients in whom CT was part of the composite reference standard showed sensitivity and specificity of 87.9% and 92.9% for all lung pathologies. It was found that there was superior sensitivity and specificity of LUS compared with chest radiograph in a subgroup analysis of pulmonary oedema and acute respiratory distress syndrome (ARDS)., Interpretation: We found that the LUS was better than chest radiograph and as good as CT in most pathologies, especially pulmonary oedema and ARDS. We believe that training in the basics of bedside LUS must be part of the medical curriculum and a low-cost ultrasound machine must be made available in medical wards, so that clinical diagnosis can be supplemented with this tool. In a low resource setting like India, where access to chest radiograph and CT may be difficult particularly in a rural setup, expertise in LUS would be helpful in easy bedside diagnosis and saving cost on a CT scan., (© The Author(s) 2022. Published by Oxford University Press on behalf of Postgraduate Medical Journal. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The duration of cryopreservation of embryos and its effect on the subsequent pregnancy outcomes, when they have been frozen for a longer duration remains a matter of concern. There is a continuous debate among studies comparing different durations of embryo cryopreservation as the results are contradictory., Aims: This study aims to find out if long-term cryopreservation of embryos has any effect on pregnancy and perinatal outcomes., Settings and Design: :Retrospective cohort study was conducted in the department of reproductive medicine and surgery in a university-level teaching hospital., Materials and Methods: The study included women who underwent frozen embryo transfer (FET) from autologous in vitro fertilisation between January 2012 and December 2020 with the duration of cryopreservation of more than 5 years as one group and 3-5 years as another group. Pregnancy and perinatal outcomes were analysed., Statistical Analysis Used: Regression analysis was performed using logistic regression by entering clinically important variables associated with pregnancy outcome, and the results were expressed as odds ratio with a 95% confidence interval (CI). All statistical analysis was performed with SPSS (version 21.0, IBM, USA)., Results: A total of 1680 FET cycles were carried out during the study period. Among these, 75 cycles with a duration of 3-5 years and 20 cycles with a duration of more than 5 years were included. Live birth rate (LBR) was 40.8% in the 3-5 years group and 35% in the more than 5 years group. After adjusting for important confounders, the LBR has no significant association in the more than 5 years group (adjusted odds ratio 1.07; 95% CI 0.34-3.32; P = 0.913) compared to the 3-5 years group., Conclusion: The duration of cryopreservation of embryos has no statistically significant effect on the pregnancy and perinatal outcomes., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Human Reproductive Sciences.)

Background: Necrotizing soft tissue infections (NSTIs) are life-threatening infections characterized by progressive destruction of muscle, fascia, and overlying subcutaneous tissue. Prospective studies in the field are few, and data from the Indian subcontinent are bleak. Prompt diagnosis and timely treatment are critical for optimal outcomes. The aims of this study are to provide detailed information on the clinical profile of patients with NSTIs and to identify predictors of mortality in order to pick up reversible factors that may improve outcomes., Materials and Methods: This study was a prospective cohort study of adult patients with NSTIs in a tertiary center in South India. All patients who were admitted to the surgical intensive care unit (ICU) of the institute with a diagnosis of NSTI were screened and enrolled. All patients were managed according to the local protocol for treatment of NSTIs and intensive care support., Results: In our cohort of patients, simple and multiple logistic regression analysis showed that four factors, namely, AKIN stage 3, shock, need for mechanical ventilation for more than 3 days, and low serum albumin values were found to be significantly associated with higher mortality., Conclusion: The successful management of these patients calls for early diagnosis, resuscitation, surgical debridement, appropriate and timely antibiotics, and early ventilatory weaning before multi-organ failure associated with shock and AKI occurs., How to Cite This Article: Kurian GP, Korula PJ, Jacob JM, Desha AMK, Karuppusami R, Kandasamy S. Patient Characteristics and Outcomes in Necrotizing Soft-tissue Infections: Results from a Prospective Cohort Study in a Tertiary Care Center Intensive Care Unit in South India. Indian J Crit Care Med 2022;26(4):452-456., Competing Interests: Source of support: Fluid Research Grant, CMC, Vellore. Conflict of interest: None, (Copyright © 2022; Jaypee Brothers Medical Publishers (P) Ltd.)

Aim: To study the prognostic significance of MRI identified tumour deposits (TD), extramural vascular invasion (EMVI), lymph node metastases (LNM) and pelvic sidewall (PSW) disease in rectal cancer., Methods: This IRB approved study was conducted on patients with stage IIA-IIIC rectal adenocarcinoma treated with neoadjuvant long course chemoradiotherapy (LCCRT) and total mesorectal excision (TME) type of surgery between 2012-2018. A radiologist blinded to outcome reviewed staging and restaging magnetic resonance imaging (MRI) for TD, EMVI, LNM and PSW. The agreement between four radiologists was studied and we obtained outcome data from a prospectively maintained database. The prognostic significance of imaging findings was assessed., Results: A total of 297 (186 males) patients with a mean age of 47.3 (SD14.4) years were included in the study. The majority had T3 (n = 206) or T4 (n = 59) stage disease. The mean duration of follow-up was 49.3 ± 25 months (6.6-101 months). 5-year overall (OS) and disease-free survival (DFS) was 84% and 74%, respectively. Staging and restaging MRI had EMVI in 49.5% and 31.3%; TD in 47.5% and 31.6%; LNM in 61.1% and 38.1% and PSW in 11.4% and 6.1%. OS was adversely affected by EMVI, TD and PSW with the adjusted HR (aHR) of 3.32, 3.31, 3.27 for staging MRI and 2.99, 3.1, 2.81 for restaging MRI, respectively, p < 0.05. DFS was affected by EMVI (aHR = 1.85, 2.33) and TD (aHR = 1.83, 2.19), p < 0.05. Persistence of these findings after LCCRT led to worst outcome. Intra- and interobserver agreement for EMVI, TD and LN was 0.789, 0.734, 0.406 and 0.449, 0.354, 0.376, respectively, p < 0.001., Conclusions: MRI identified that TD, EMVI and PSW disease are independent poor prognostic indicators in rectal cancer patients. Interobserver agreement for these findings was moderate to fair., (© 2021 The Association of Coloproctology of Great Britain and Ireland.)

Background: Longitudinal studies are important to understand patterns of growth in children and limited in India. It is important to identify an approach for characterising growth trajectories to distinguish between children who have healthy growth and those growth is poor. Many statistical approaches are available to assess the longitudinal growth data and which are difficult to recognize the pattern. In this research study, we employed functional principal component analysis (FPCA) as a statistical method to find the pattern of growth data. The purpose of this study is to describe the longitudinal child growth trajectory pattern under 3 years of age using functional principal component method., Methods: Children born between March 2002 and August 2003 (n = 290) were followed until their third birthday in three neighbouring slums in Vellore, South India. Field workers visited homes to collect details of morbidity twice a week. Height and weight were measured monthly from 1 month of age in a study-run clinic. Longitudinal child growth trajectory pattern were extracted using Functional Principal Component analysis using B-spline basis functions with smoothing parameters. Functional linear model was used to assess the factors association with the growth functions., Results: We have obtained four FPCs explained by 86.5, 3.9, 3.1 and 2.2% of the variation respectively for the height functions. For height, 38% of the children's had poor growth trajectories. Similarly, three FPCs explained 76.2, 8.8, and 4.7% respectively for the weight functions and 44% of the children's had poor growth in their weight trajectories. Results show that gender, socio-economic status, parent's education, breast feeding, and gravida are associated and, influence the growth pattern in children., Conclusions: The FPC approach deals with subjects' dynamics of growth and not with specific values at given times. FPC could be a better alternate approach for both dimension reduction and pattern detection. FPC may be used to offer greater insight for classification., (© 2022. The Author(s).)

Background: Intraoperative hand-moulded cranioplasty and polymethylmethacrylate (PMMA) prostheses made from bone impressions are economical but the cosmetic results are less than satisfactory. Commercially available customized prostheses perform better but are prohibitively expensive. We evaluate the performance of a locally developed, low-cost customized PMMA cranioplasty prosthesis., Objective: To compare the cosmetic outcome of 3 types of PMMA cranioplasty as well as with objective measurements on postoperative CT scans METHODS: This study includes 70 patients who underwent cranioplasty between March 2016 and June 2020. In this period, patients had their cranioplasty prostheses made by intra-operative hand moulding (HM), by using the removed bone as a template and making a bone impression (BI) or by 3D printing the prosthesis based on a CT scan. Cosmetic outcomes were assessed by the patient and the operating surgeon on an 8-point scale. The degree of measured anthropometric asymmetry was measured on a postoperative CT scan and correlated with the cosmetic outcome., Results: Our locally produced 3D-printed cranioplasty prostheses showed a statistically better performance in cosmetic scores when compared to the HM and BI (p value < 0.001). CT anthropometric measurements significantly correlated with cosmetic outcome (p value 0.01) CONCLUSION: Our 3D cranioplasty prostheses had better cosmetic outcomes than HM and BI prostheses, and our technique is able to produce them at 10% of the cost of the currently available commercial customized prostheses., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Introduction: This study assessed the long-term survival and the prognostic variables affecting survival following pulmonary metastasectomy (PM) secondary to childhood solid tumors., Materials and Methods: A retrospective analysis was done on 22 children who underwent PM for solid tumors between January 2007 and February 2020. The overall survival (OS) and event-free survival (EFS) at the end of the study period were noted. Tumor histology, completeness of resection, disease-free interval, laterality, location, number, and size of lung nodules were assessed for their significance in contributing to survival., Results: High-grade osteosarcoma (54.5%), followed by Wilms' tumor (18.2%), was the most common histological types. Unilateral nodules (59.1%) situated in a peripheral, sub-pleural location (91%) were the most common presentation. Pleural extension was noted in 12 (54.5%) patients. Synchronous pulmonary metastases were noted in 12 (54.5%) patients. Two developed metastases while undergoing chemotherapy and eight after the completion of therapy. The EFS and OS were both 31.8% at a median follow-up of 15.5 months (range 3-129 months). The median time required for an event to occur was 4 months (95% confidence interval [CI]: 1.4, 6.6 months) and median post-PM survival interval was 17 months (95% CI: 6.6, 27.4 months). Significant association was noted between preoperative tumor response to chemotherapy ( P = 0.002) and survival., Conclusion: PM can improve survival in a select group of children with metastatic solid tumors. Favorable tumor response to chemotherapy was found to be a significant prognostic factors influencing survival., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Indian Association of Pediatric Surgeons.)

We conducted a review of hospital records of infants with acute encephalitis syndrome with bilateral symmetrical basal ganglia infarcts, between 2011-2015, at a single center in Assam. Thiamine (as part of multivitamin injection) was used in the treatment of 23 infants and not used in 27; Only 1 (3.7%) infant died in the former group and 20 infants (86.9%) died in the latter [RR (95% CI) 0.04 (0.006,0.29); P<0.001). Two infants on follow-up had normal development, both in the thiamine group. The study suggests the possibility of subclinical thiamine deficiency, mitochondrial diseases, or SLC19A3 gene mutation in this population.

To achieve optimal debulking, cytoreductive surgery often involves diaphragm stripping. We describe our complications and survival outcomes after diaphragm surgery in epithelial ovarian cancer. A retrospective analysis on patients with advanced stage epithelial ovarian cancer between January 2012 and September 2019. The details of the diaphragmatic resections and stripping and their complications were looked into. During the study period, 616 patients with epithelial ovarian cancers were operated of which, 81 (13.2%) had diaphragm surgery. The majority underwent diaphragm stripping (60%) while 33% had resection and 7% cases had diaphragmatic nodule excision. Optimal debulking was achieved in 89% of cases. The complexity of surgery was intermediate in 64% of patients and complex in 33% as per Aletti's scoring. Mean operating time was 300 min (SD113). Moderate to severe pleural effusion was seen in 26 (32. %) patients necessitating pleural tapping in 16% and single lumen pleurex catheter insertion in 11%. Median recurrence-free and overall survival were 22 (95% CI 16.9-27) and 32 months (95% CI 25.5-38) respectively. Diaphragm stripping and resection is an important step in achieving optimal debulking of advanced and recurrent ovarian cancer. Diaphragmatic disease clearance is a necessary skill to be acquired by the gynaecologic oncology surgeons. Choosing the patients correctly and anticipation of complications can reduce morbidity and mortality., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© Indian Association of Surgical Oncology 2021.)

Background: A subgroup of pertrochanteric fractures-namely, the AO/OTA 31A3 fracture-continues to be a difficult problem to treat, even with cephalomedullary nails. We present the results for 26 patients with a 31A3 fracture treated with the angled blade plate., Methods: The records of 26 consecutive patients with a 31A3 fracture that was treated operatively with the angled blade plate device between 2007 and 2012 at our center were reviewed, and the patients were contacted for follow-up. The functional outcome (traumatic hip rating score) and radiographic outcome (the neck-shaft angle at the time of fixation and final follow-up) were obtained for 20 of the 26 patients at a minimum follow-up of 1 year., Results: All 26 patients had primary surgery. At final review, 2 patients had died and 4 had been lost to follow-up. Of the 4 patients lost to follow-up, 2 had revision of the fixation with the angled blade plate. Of the 20 patients with follow-up, 1 had malreduction and implant failure but eventually had healing after revision of the fixation with the angled blade plate. The mean traumatic hip rating score at the time of follow-up was 50.0 with 4, 14, and 2 patients having excellent, good, and failed outcomes, respectively. The mean neck-shaft angle at the time of final union was 126.16°, which was an average of 4° less than that on the unaffected side. However, this did not correlate with functional outcome. There was no significant difference between the immediate postoperative and final neck-shaft angles., Conclusions: This study demonstrated that blade plate fixation for 31A3 fractures is associated with low rates of failure (15%), revision surgery (15%), and infection (15%), which are comparable with the results of nail fixation (range, 5% to 12%) and superior to those of sliding hip screw fixation. This large series demonstrates that the angled blade plate can be utilized for these complex fractures and should be part of the armamentarium for these injuries., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G550)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Study Question: What is the knowledge, anxiety levels and attitudes of infertile couples towards coronavirus disease 2019 (COVID-19) and its impact on undergoing self-funded treatment cycles?, Summary Answer: In spite of a high level of awareness about COVID-19, anxiety levels were low and many participants wanted to continue fertility treatment during the pandemic., What Is Known Already: The COVID-19 pandemic has strained the already overburdened public health infrastructure in many of the resource-limited settings across the world. After an initial decision to suspend fertility treatments, regulatory authorities advocated phased resumptions of treatment. Owing to limited healthcare resources and the detrimental impact of COVID-19 on the economy and job losses, fertility services have been disproportionately affected. It is important to understand the perceptions of infertile couples, who are the key stakeholders in shared decision-making, especially for self-funded treatments, on the continuation of fertility treatment during the current COVID-19 pandemic., Study Design Size Duration: This was a questionnaire-based cross-sectional study conducted among 502 participants (251 infertile couples) at a tertiary level infertility clinic between May 2020 and November 2020. The study recruitment period (6 months) coincided with the increase and peak of COVID-19 infection in India. The study included infertile couples who had attended the clinic either for assessment or fertility treatment., Participants/materials Setting Methods: An interviewer administered the questionnaire survey, which was conducted in two stages for each participant. In the first stage, knowledge about COVID-19 and anxiety levels caused by the ongoing pandemic were assessed using a validated Generalized Anxiety Disorder-7 (GAD-7) tool. Following this, all the participants were provided with a COVID-19 information pamphlet. Subsequently, in the second stage, participants were administered another questionnaire to assess their attitudes towards fertility treatment and pregnancy during the COVID-19 pandemic., Main Results and the Role of Chance: The results showed that the knowledge levels and awareness about COVID-19 was high among infertile couples attending the infertility clinic. The majority of the participants were aware of the mode of spread (87.6-93.4% correct answers to different questions), common symptoms (64.1-96.2%) and the importance of preventative measures (95.6-97.4%). Most of the participants (474/502; 94.4%) did not show anxiety when being assessed using GAD-7. A vast majority (96.5-99.2%) of the participants were in agreement with the need for following preventative measures for reducing the spread of COVID-19. About one-third of the participants wanted to delay the fertility treatment until the pandemic is over (166/502; 33.1%). Approximately 42.2% (212/502) of the participants did not feel the need to suspend fertility treatment during the pandemic. Further analysis revealed that participants' education levels significantly influenced the desire to continue fertility treatment: participants with lower levels of education (below graduate) were less likely to continue fertility treatment (adjusted odds ratio 0.34, 95% CI, 0.12-0.98)., Limitations Reasons for Caution: Questionnaire-based responses could have limited the ability of the interviewer to capture the entire range of thoughts and views of the participants on the COVID pandemic and their fertility treatments. Furthermore, a language barrier was encountered for some couples for which assistance from a translator was sought., Wider Implications of the Findings: Given the impact of infertility and the associated stigma, public health policy makers, regulatory authorities and fertility societies should consider a way to sustain the treatment options and develop appropriate guidelines to continue treatment, particularly when much of the world is experiencing the second and third waves of the COVID pandemic., Study Funding/competing Interests: This study has not received any specific grant from funding agencies in the public, commercial or not-for-profit sectors. M.S.K. is an associate editor with Human Reproduction Open . The other authors have no competing interests to declare., Trial Registration Number: N/A., (© The Author(s) 2021. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology.)

Study Design: Retrospective case series., Purpose: This study aimed to examine the efficacy of composite grip strength as a marker of surgical outcome in patients with moderate to severe degenerative cervical myelopathy., Overview of Literature: Degenerative cervical myelopathy causes loss of dexterity, muscle strength, and sensations in the hand. The impact of surgical management on improvement in composite grip strength has received scant attention., Methods: This retrospective study was performed on degenerative cervical myelopathy patients with a complete composite grip strength assessment between January 2013 to January 2019. The Biometrics E-link hand kit was used for the assessment. The following parameters were measured: maximum grip strength, sustained grip strength, three-jaw pinch, maximum key pinch, and sustained key pinch. The pre- and postoperative functional status was assessed using the Nurick grade and the modified Japanese Orthopaedic Association (mJOA) score., Results: A total of 40 patients were included in the study. The mean patient age was 51.9 years. The mean preoperative Nurick grade was 3.5 and the mJOA score was 10.9. The anterior approach was used in 25 patients, and the posterior approach was used in 15 patients. Four patients developed complications. Degenerative cervical myelopathy resulted in decreased handgrip and pinch strength as compared to normative Indian data. There was a significant improvement in the postoperative composite grip strength for all five parameters. There was no differential improvement between the anterior and posterior surgical groups. The improvement in the composite grip strength correlated with the improvement in functional scores., Conclusions: Composite grip strength analysis is an objective method for assessing the impact of degenerative cervical myelopathy on grip strength and monitoring the postoperative improvement. Decompressive surgery resulted in global improvement in all the parameters of composite grip strength.

Positron emission tomography-computed tomography (PET-CT) has been used as an imaging modality in workup of fever of unknown origin (FUO). The aim of our study is to evaluate the diagnostic utility of PET-CT in FUO workup in a resource-limited setting. We also looked at laboratory parameters as predictors of contributory PET-CT scans and propose an algorithm for evaluation of FUO in resource-limited tropical regions. This retrospective observational study included patients admitted for FUO workup under general medicine in a teaching hospital in South India from June 2013 to May 2016. PET-CT was done when the patient remained undiagnosed after a detailed clinical assessment and first- and second-tier investigations. Among 43 patients included in our study, a definite diagnosis was established in 74% (32). Noninfectious inflammatory diseases, infections, malignancies, and miscellaneous diseases were diagnosed in 37.2% (16/43), 23.3% (10/43), 9.3% (4/43), and 4.7% (2/43), respectively. Tuberculosis was the single most common disease seen in 20.9% (9/43). PET-CT scans were contributory toward establishment of final diagnosis in 90.7% (39/43). High C-reactive protein (CRP) and aspartate aminotransferase (AST) levels were associated with contributory PET-CT scans ( P = 0.006 and 0.011, respectively). PET-CT delineating organ/tissue for diagnostic biopsy was associated with final diagnosis of infectious disease ( P = 0.001). Sensitivity, specificity, and positive and negative predictive value of PET-CT scans were 76.9% (20/26), 33.3% (2/6), 83% (20/24), and 25% (2/8), respectively. High CRP and AST were predictors of contributory PET-CT scans. PET-CT scans have high sensitivity and positive predictive value when used in evaluation of FUO. Although it is a useful tool in FUO workup, especially in the diagnosis of tropical infections, PET-CT should be done after a comprehensive clinical assessment and basic investigations., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 World Journal of Nuclear Medicine.)

Background: It is well known that seasonal variations influence natural conception and birth rates variably in different populations. It has been hypothesised that similar seasonal influences may affect treatment outcomes following assisted reproductive technology (ART). However, most studies report conflicting results., Aim: The aim of the study is to elucidate whether seasonality had any impact on the treatment success of the ART program., Study Setting and Design: We conducted a retrospective cohort study at a university-level tertiary care hospital in South India., Materials and Methods: All couples who underwent ART between January 2012 and December 2016 were included in the study. We divided the study population into three groups based on the seasonal differences experienced in our region. The primary outcome was live birth rate (LBR)., Statistical Analysis: Univariate and multiple logistic regression models were used to compare outcomes and results reported as odds ratio (OR) and 95% confidence interval (CI)., Results: Univariate analysis revealed no significant difference in LBR in monsoon season (174/651, 26.7% vs. 83/319, 26.0%; OR 1.04, 95% CI 0.77,1.41; P = 0.81) as compared to summer. However, LBR was significantly higher in winter season (114/341, 33.4% vs. 83/319, 26.0%; OR 1.43; 95% CI: 1.02, 2.00; P = 0.04). Further, multivariate analysis following adjustment for various confounding factors revealed no significant statistical difference in LBR in monsoon (adjusted odds ratio [aOR], 0.92; 95% CI: 0.66, 1.26; P = 0.59) or winter (aOR 1.32; 95% CI: 0.92, 1.88; P = 0.13) as compared to summer season., Conclusion: The current study found no significant effect of seasonal variation on LBR following ART., Competing Interests: Dr. Mohan S Kamath is the Deputy Editor for Journal of Human Reproductive Sciences. However, for the current manuscript, he was not involved in the editorial decisions or blind peer review process., (Copyright: © 2021 Journal of Human Reproductive Sciences.)

Sentinel lymph node biopsy (SLNB) is done by different techniques in clinically node-negative patients with early breast cancer. In this study, we aim to estimate the identification rates, positivity rates, cost-effectiveness, and outcomes for patients who underwent sentinel node biopsy using methylene blue dye alone. This was a retrospective review of 172 patients with early breast cancer (cT1-3, N0) who underwent SLNB using methylene blue dye alone between January 2014 and December 2018 including their follow-up details until December 2019. The mean age was 51 ± 10.3 (range: 28 to 76) years. There were 63 (36.6%) patients with cT1 tumor, 108 (62.7%) with cT2, and only 1 patient with cT3 tumor. Breast conservation surgery was performed in 62 (36%) while the remaining 110 (64%) underwent simple mastectomy. Sentinel nodes were successfully identified in 165 (95.9%) with a positivity rate of 23.6%. There was no dye-related adverse reactions intra-operatively. The mean duration of follow-up was 26.68 ± 15.9 months (range: 1-60). Chronic arm pain was present in 7 (4%) while none of the patients had lymphedema or restriction of shoulder joint motion. There were no documented axillary nodal recurrences in this cohort. Eight (4.65%) patients were detected to have systemic metastasis. One patient died of brain metastasis from bilateral breast cancer. The mean disease-free survival was 57 months (95% CI: 55-59). Sentinel lymph node biopsy using methylene dye alone is a safe, simple, and cost-effective alternative to isosulfan blue or radio isotope technique in surgical centers with resource constraints., Competing Interests: Conflict of InterestThe authors declare that they have no conflict of interest., (© Indian Association of Surgical Oncology 2021.)

Background: Lower serum 25-hydroxyvitamin D [25(OH)D] is associated with greater adiposity and adverse cardiometabolic risk profile. The evidence is inconsistent among South Asian Indians. We aimed to examine associations between 25(OH)D and cardiovascular (CVD) risk markers in a rural and urban cohort from South India., Subjects/methods: In this cross sectional study, 373 individuals (men, n = 205) underwent detailed CVD risk marker assessment including anthropometry [body mass index (BMI), waist, (WC) and hip circumferences (HC)], body composition analysis using dual energy x-ray absorptiometry (DXA), blood pressure and biochemical analysis (glucose, insulin and lipids). The distribution of CVD risk factors were compared across serum 25(OH)D levels, stratified as deficiency (<20 ng/ml), insufficiency (20 to 29 ng/ml) and normal (≥30 ng/ml) levels. Multiple regression analysis, adjusting for potential confounders, was used to study associations of 25(OH)D with adiposity and cardiometabolic traits., Results: The mean and standard deviation (SD) of age, BMI and 25(OH)D levels were 41.4 (1.1) years, 25.5 (4.8) kg/m2 and 23.4 (10.4) ng/ml respectively. The prevalence of 25(OH)D deficiency was 39.9% in this cohort. Individuals in the 25(OH)D deficiency category had significantly higher mean (SD) BMI [26.6 (5.1) kg/m2], waist circumference [89.9 (12.5) cm] and total fat mass [20.6 (7.9) kg] compared with the Vitamin D sufficient group [BMI: 24.0 (4.4); WC 84.7 (12.0); total fat mass: 15.2 (6.8)]. Significantly inverse associations were observed with DXA measured total and regional fat depots with 25(OH)D levels, while anthropometric indices of adiposity showed significant inverse association only in women. After adjusting for total fat mass, no significant associations were observed between 25(OH)D and the cardiometabolic traits., Conclusions: Our results confirm that lower 25(OH)D is independently associated with both total and regional adiposity, but not with cardiometabolic traits, in this population., Competing Interests: The authors have declared that no competing interests exist.

Acute necrotizing encephalopathy after an acute febrile illness, although initially described exclusively in the pediatric age group, has been recently shown to have an adult onset as well. In this study, we describe 10 patients (16 years of age or older) with acute necrotizing encephalopathy. In our study, bilateral thalamic involvement with the trilaminar pattern of diffusion restriction on MR imaging was the predominant finding seen in all of the patients reviewed. Ancillary findings of cerebral white matter, brain stem, and cerebellum involvement with sparing of the basal ganglia were also noted. A poorer outcome was observed in patients with a higher degree of thalamic involvement. The cause of an underlying infection was identified in 4 patients (dengue in 3 and influenza in 1). Overall, a sizeable portion of young adults with acute necrotizing encephalopathy have shown a poorer outcome, with dengue being an important underlying trigger in an endemic region., (© 2020 by American Journal of Neuroradiology.)

Study Question: Does oral antioxidant pretreatment for the male partner improve clinical pregnancy rate in couples undergoing ART for male factor subfertility?, Summary Answer: There was no significant difference in clinical pregnancy rate following oral antioxidant pretreatment for male partner in couples undergoing ART for male factor subfertility compared to no pretreatment., What Is Known Already: Damage to sperm mediated by reactive oxygen species (ROS) contributes significantly to male factor infertility. The ROS-related injury reduces fertilization potential and adversely affects the sperm DNA integrity. Antioxidants act as free radical scavengers to protect spermatozoa against ROS induced damage. During ART, use of sperms which have been exposed to ROS-mediated damage may affect the treatment outcome. Pretreatment with antioxidants may reduce the ROS-mediated sperm DNA damage. Currently, antioxidants are commonly prescribed to men who require ART for male factor subfertility but there is ambiguity regarding their role., Study Design Size Duration: This was an open label, randomized controlled trial conducted at a tertiary level infertility clinic between February 2013 and October 2019. The trial included 200 subfertile couples who were undergoing ART treatment for male factor subfertility., Participants/materials Setting Methods: Couples were randomized into treatment arm (n = 100) and control arm (n = 100). In the treatment arm, the male partner received oral antioxidants (Vitamin C, Vitamin E and Zinc) for 3 months just prior to the ART cycle. In the control arm, no antioxidant was given to the male partner. The primary outcome was clinical pregnancy rate, while live birth rate (LBR), miscarriage rate and changes in semen parameters were the secondary outcomes., Main Results and the Role of Chance: Out of 200 women randomized, 135 underwent embryo transfer as per protocol. Following intention to treat analysis, no significant difference was noted in clinical pregnancy (36/100, 36% vs 26/100, 26%; odds ratio (OR) 1.60, 95% CI 0.87 to 2.93) and LBR (25/100, 25% vs 22/100, 22%; OR 1.18, 95% CI 0.61 to 2.27) between antioxidant and no pretreatment arms. The clinical pregnancy rate per embryo transfer was significantly higher following antioxidant pretreatment (35/64, 54.7% vs 26/71, 36.6%; OR 2.09, 95% CI 1.05 to 4.16) compared to no pretreatment. There was no significant difference in LBR per embryo transfer (25/64, 39.1%, vs 22/71, 31.0%; OR 1.43, 95% CI 0.70 to 2.91) after antioxidant pretreatment versus no pretreatment. The semen parameters of sperm concentration (median, interquartile range, IQR) (18.2, 8.6 to 37.5 vs 20.5, 8.0 to 52.5, million/ml; P  =   0.97), motility (median, IQR) (34, 20 to 45 vs 31, 18 to 45%; P  =   0.38) and morphology (mean ± SD) (2.0 ± 1.4 vs 2.2 ± 1.5%; P  =   0.69) did not show any significant improvement after intake of antioxidant compared to no treatment, respectively., Limitations Reasons for Caution: The objective assessment of sperm DNA damage was not carried out before and after the antioxidant pretreatment. Since the clinicians were aware of the group allotment, performance bias cannot be ruled out., Wider Implications of the Findings: The current study did not show any significant difference in clinical pregnancy and LBR following antioxidant pretreatment for the male partner in couples undergoing ART for male subfertility. The findings need further validation in a larger placebo-controlled randomized trial., Study Funding/competing Interests: This trial has been funded by Fluid Research grant of Christian Medical College, Vellore (internal funding). The authors have no conflicts of interest to declare., Trial Registration Number: CTRI/2013/02/003431., Trial Registration Date: 26 February 2013., Date of First Patient’s Enrolment: 11 February 2013., (© The Author(s) 2020. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology.)

Objective: To determine whether socioeconomic deprivation affects IVF outcome independent of the number of cycles undertaken., Design: A retrospective review of prospectively collected data., Setting: A tertiary level fertility clinic in the North of England., Population: All participants undergoing their first fresh single-embryo transfer, funded by the National Health Service (NHS), between January 2012 and December 2017., Methods: For each case, identified from the clinic database, we recorded the following: age; body mass index; FSH; number of eggs retrieved; ethnicity; cause of subfertility; stage of embryo transfer; and whether any adjuncts i.e. EmbryoGlue ® or Time Lapse Imaging were used. Socio-economic deprivation was assessed using the Index of Multiple Deprivation (IMD) determined by the residential postcode., Main Outcome Measures: Clinical pregnancy (CP) and live birth (LB) rates across IMD quintiles., Results: Three thousand ninety-one women were included. Overall, CP and LB rates were 35.9% and 31.3% respectively. CP rates increased significantly from 31.0% in the most deprived group to 38.8% in the least deprived group (P < 0.01). Similarly, LB rates were significantly lower in the most deprived group compared with the least deprived group (26.8 versus 35.4%, P < 0.01). After adjusting for confounding variables, women in the least deprived group were significantly more likely to have a LB (aRR 1.18, 95% CI 1.00-1.39) than women in the most deprived group., Conclusions: More socio-economically deprived patients are significantly less likely to achieve a LB than less deprived patients independent of the number of cycles of IVF undertaken., Tweetable Abstract: More deprived patients are less likely to have a LB per cycle of IVF than less deprived patients., (© 2019 Royal College of Obstetricians and Gynaecologists.)

Background: Failure of Non-Invasive Ventilation (NIV) is associated with increased morbidity and mortality among critically ill patients. Although there is evidence of association between disease related factors and NIV failure, it is unclear whether factors related to NIV application contribute to NIV failure., Objectives: To evaluate NIV failure rate and factors associated with NIV failure., Design, Settings and Outcomes: Prospective, observational, pilot study conducted in a 23-bed, tertiary care Intensive Care Unit (ICU). NIV failure was defined as application of NIV resulting in intubation or death in ICU., Results: Amongst 238 patients admitted with respiratory failure, NIV was administered to 60 patients (34 males, 26 females) for a total of 70 application episodes. The etiology of respiratory failure included acute pulmonary edema (28.6%), acute lung injury (22.9%) and pneumonia (15.7%). The mean (SD) age was 62 (17.6) years, BMI 32.0 (8.5) kg/m 2 and median APACHE-II score 17.5 (14.0-23.8). NIV failure occurred in 22 out of 70 applications (31.4% [95%CI 20.0-43.0]). NIV failure assessed by simple logistic regression analysis, was associated with admission diagnosis (OR 6.0, 95%CI: 1.3-28.7, p = 0.03), use of bi-level NIV-PS (OR 5.00, 95%CI: 1.04-24.1, p = 0.04), presence of nasogastric tube (OR 6.20, 95%CI: 1.9-19.8, p < 0.01) and with short NIV breaks in the 2nd 24-hours (OR 0.96, 95%CI: 0.91-0.99, p = 0.04)., Conclusion: NIV failure was observed in 31.4%. Factors associated with NIV failure were etiology of respiratory illness, type of NIV support and short NIV breaks, presumably reflecting illness severity or progress of disease. The presence of a nasogastric tube during application of NIV may adversely impact NIV application., (Copyright © 2018 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Data from large-volume centers in developed countries, using dedicated tools, show a high success rate with a good safety record for the percutaneous lead removal procedure. However, there are constraints to replicate the results in a resource-poor setting and there is limited data from India., Methods: We retrospectively analyzed lead removal procedures performed in our institution from 2008 to 2019., Results: Seventy-five patients underwent percutaneous removal of 138 leads. Of these, 44 procedures and 80 leads qualified as extraction with a median dwell time of 52.1 (IQR 28.2-117.2) months. Overall, 33/44 (75.0%) procedures were successful and 65/80 (81.2%) leads were successfully extracted. Manual traction was successful in the extraction of 44/57 (77.2%) leads. All leads implanted less than 2.7 years could be removed with manual traction alone. Specialized tools were used in 23 leads and 21 (91.3%) of those could be successfully extracted. Inability to use dedicated tools was an independent predictor of procedural failure (adjusted OR 14.0; 95% CI 1.8-110.2; p-value 0.012). Right-sided implant (adjusted OR 12.6; 95% CI 1.3-119.5; p-value 0.027) was also independently associated with failure. There was 1 death (1.3%) and minor complications occurred in 6 (8.0%) patients., Conclusions: In a resource-limited setting, percutaneous lead extraction of predominantly pacemaker leads by manual traction methods achieved success in extracting about three-fourths of the leads. Inability to use specialized tools was the main factor limiting success. The complication rate was low., Competing Interests: Declaration of competing interest The authors declare no conflict of interest for this study., (Copyright © 2019 Indian Heart Rhythm Society. Production and hosting by Elsevier B.V. All rights reserved.)