Cardiovascular Autonomic Deficits in Different Types of Achalasia.

Background and objective Achalasia cardia is a primary esophageal motility disorder, and the etiopathology of this disease's progression is not known. Moreover, autonomic dysfunction has not been studied in different types of achalasia. In light of this, we aimed to address this lack of data in this study. Methods The diagnosis of achalasia was done using high-resolution esophageal manometry (HRM)-based Chicago classification v4.0. Autonomic function tests (AFT) such as the head-up tilt test, deep breathing test (DBT), Valsalva maneuver (VM), handgrip test (HGT), and cold pressor test (CPT), as well as the heart rate variability (HRV) test, were performed among the cohort and the results were compared with those of 39 age- and sex-matched healthy controls. Results AFT and HRV tests were done on 62 patients (30 achalasia type I, 28 type II, and 4 type III) and compared with 39 age- and sex-matched healthy controls. The mean duration of symptoms, high Eckardt score, and dysphagia were most common in type I achalasia, followed by type II and III. The results of AFT showed a generalized loss of parasympathetic and baroreflex-independent sympathetic reactivity in all types of achalasia. However, baroreflex-dependent cardiovascular adrenergic reactivity was normal. Regarding cardiac autonomic tone, there was a loss of parasympathetic and sympathetic influence, but sympathovagal balance was maintained. The severity of the loss of autonomic functions was higher in type I, followed by type II. Conclusions In all types of achalasia, parasympathetic reactivity, baroreflex-independent sympathetic reactivity, and cardiac autonomic tone were lower compared to healthy controls, and the severity of dysfunction increased during the progression of the disease from type II to type I.

Transforaminal Endoscopic Ventral Stenosis Decompression in Calcified Lumbar Disc Herniation: A Long Term Outcome in 79 Patients.

BACKGROUND: Calcified lumbar disc herniations (CLDH) causing calcified ventral stenosis pose a therapeutic challenge to the treating surgeon due to their neural adhesions, location, and hardness. METHODS: This retrospective study analyzed all the cases of CLDH/calcified ventral stenosis managed by transforaminal endoscopic lumbar discectomy with a minimum follow-up of 24 months. The preoperative images were analyzed for the level, migration; and grade (Lee's migration zones), and location (Michigan State University classification). Detailed surgical technique and intraoperative parameters including the duration of surgery and complications have been recorded. The clinical parameters including visual analog scale (VAS), Oswestry disability index (ODI), length of stay in hospital, days of return to basic work, and patient satisfaction index were analyzed. Postoperatively the images were analyzed for the adequacy of decompression. RESULTS: The mean VAS for back pain and leg pain was 4.7 ± 2.6 (0-9), and 7.45 ± 2.2 (1-10), respectively. The mean preoperative ODI was 78.2 ± 13.2 (63.2-95.6). Nineteen patients (24%) had neurological deficits preoperatively. The mean duration of surgery was 90.5 ± 15.8 (58-131) minutes. Postoperative magnetic resonance imaging revealed adequate decompression in 97.5% (n = 77). The mean duration of hospital stay was 1.05 ± 0.22 (1-2) days, and the postoperative back and leg pain VAS was 1.14 ± 1.2 (0-3) (P < 0.05) and 1.7 ± 0.5 (0-6) (P < 0.05), respectively. The ODI at final follow-up was 6.5 ± 3.7 (2.2-18) (P < 0.05). Neurological recovery occurred in 17 (89.5%) patients and they returned to basic work/jobs in 19.5 ± 3.3 (14-26) days. The mean patient satisfaction index was 1.18 ± 0.47 (1-2) at a mean follow-up of 5.52 ± 2.91 (2-12.75) years. CONCLUSIONS: Transforaminal endoscopic lumbar discectomy is a complete, safe, and efficacious procedure in patients with CLDH with earlier recovery considering the surgery is performed with the patient being awake.

A novel methodology to demonstrate vestibulo-ocular reflex using caloric stimulation in undergraduate physiology laboratory.

The study aims to develop a novel methodology to demonstrate the vestibulo-ocular reflex (VOR) and nystagmus by caloric stimulation in an undergraduate medical physiology laboratory. The experimental setup involved two sets of electrodes: one set positioned laterally to both eyes, and another set positioned vertically over either the right or left eye. The caloric method is used to stimulate ears, which involves irrigation of warm (44°C) and cold (30°C) water into the ears while maintaining a temperature difference of approximately ±7°C from the body temperature. The changes in chorioretinal potential were calibrated to angular displacement by a two-point calibration method, and angular velocity was derived after taking the first-time derivative. The results obtained from the digital data acquisition system were compared to the traditional instrument used in our Otorhinolaryngology Department [Interacoustics Videonystagmography (VNG) System for hospitals, medical grade] for the normal subject's data. No significant differences in angular velocity were noted (P > 0.05). The cold stimuli elicit a more pronounced VOR compared to the warm stimuli. It has been consistently observed that the onset of nystagmus occurs approximately 20 s after irrigation, reaching its peak intensity between 45 and 90 s, and gradually diminishing until it ceases after approximately 200 s. Our developed methodology enables the recording and quantification of nystagmus using easily accessible equipment. This study serves the goal of visualizing the physiological process of VOR and thereby fulfills the goal of an effective teaching tool for demonstrating to undergraduate medical students.NEW & NOTEWORTHY We developed a novel methodology to demonstrate and visualize the most common and important physiological phenomenon like the vestibulo-ocular reflex as a teaching module for undergraduate students.

Long-term outcomes of laparoscopic Heller's myotomy with angle of His accentuation in patients of achalasia cardia.

BACKGROUND: Laparoscopic Heller's myotomy (LHM) is an established treatment for achalasia cardia. Anti-reflux procedures (ARP) are recommended with LHM to reduce the post-operative reflux though the optimal anti-reflux procedure is still debatable. This study reports on the long-term outcomes of LHM with Angle-of-His accentuation (AOH) in patients of achalasia cardia. METHODS: One hundred thirty-six patients of achalasia cardia undergoing LHM with AOH between January 2010 to October 2021 with a minimum follow-up of one year were evaluated for symptomatic outcomes using Eckardt score (ES), DeMeester heartburn (DMH) score and achalasia disease specific quality of life (A-DsQoL) questionnaire. Upper gastrointestinal endoscopy, high resolution manometry (HRM) and timed barium esophagogram (TBE) were performed when feasible and rates of esophagitis and improvement in HRM and TBE parameters evaluated. Time dependent rates of success were calculated with respect to improvement in ES and dysphagia-, regurgitation- and heartburn-free survival using Kaplan-Meier analysis. RESULTS: At a median follow-up of 65.5 months, the overall success (ES ≤ 3) was 94.1%. There was statistically significant improvement in ES, heartburn score and A-DsQoL score (p < 0.00001, p = 0.002 and p < 0.00001). Significant heartburn (score ≥ 2) was seen in 12.5% subjects with 9.5% patients reporting frequent PPI use (> 3 days per week). LA-B and above esophagitis was seen in 12.7%. HRM and TBE parameters also showed a significant improvement as compared to pre-operative values (IRP: p < 0.0001, column height: p < 0.0001, column width: p = 0.0002). Kaplan-Meier analysis showed dysphagia, regurgitation, and heartburn free survival of 75%, 96.2% and 72.3% respectively at 10 years. CONCLUSIONS: LHM with AOH gives a lasting relief of symptoms in patients of achalasia cardia with heartburn rates similar to that reported in studies using Dor's or Toupet's fundoplication with LHM. Hence, LHM with AOH may be a preferred choice in patients of achalasia cardia given the simplicity of the procedure.

Long-term functional and radiological outcomes of cervical disc arthroplasty at a tertiary level spine center in India: A retrospective cohort analysis with minimum 2 years of follow-up.

Context: Cervical disc arthroplasty (CDA) was developed for the treatment of cervical disc disease with the potential advantages of preservation of physiological motion at a discal level, thereby potentially reducing adjacent level stresses and degeneration, which were a known complication of anterior cervical arthrodesis. The objective of this study was the assessment of long-term functional and radiological outcomes overtime in all the patients who underwent CDA from 2011 to 2019 at our institute. Materials and Methods: Forty-eight patients who underwent CDA (2011-2019) with a minimum 2-year follow-up were retrospectively evaluated. The functional outcome included the Visual Analog Score (VAS) and Neck Disability Index (NDI). Radiographs were assessed for range of motion (ROM) at the index surgical level, presence of heterotopic ossification (HO), and adjacent segment degeneration. Results: The mean follow-up was 5.79 ± 2.96 (2.16-11.75) years. Significant improvement (P < 0.05) was observed in the VAS (8.91 ± 2.52 [preoperative] to 0.89 ± 1.27 [follow-up]) and NDI (65.5% ±23.06% [preoperative] to 4.79 ± 3.87 [follow-up]) score. Motion at index level increased significantly from 5.53° preoperatively to 7.47°, and 92% of the implanted segments were still mobile (referring to the threshold of ROM > 3°). HOs are responsible for the fusion of 4/50 (8%) levels at the last follow-up. Distal and proximal adjacent disc degeneration occurred in 36% and 28% of patients, respectively. No migration of the implant was observed on the radiograph. Conclusion: Our study showed favorable clinical outcome of CDA with preservation of ROM at the index surgical level. CDA can be a promising alternative to anterior cervical arthrodesis when properly indicated.

Comparative Study on Accuracy of Intra-Operative Computed Tomography-Navigation Based Pedicle Screw Placement With Skin vs Bone Fixed Dynamic Reference Frame in Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: To compare the accuracy of intra-operative navigation-assisted percutaneous pedicle screw insertion between bone fixed and skin fixed dynamic reference frame (DRF) in Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). METHODS: Between October 2018 and September 2022, patients who underwent MIS-TLIF were included in this study with DRF fixed either on bone (group B) or skin (group S). Pedicle screws were inserted under the guidance of intra-operative Cone bean Computed tomography (cbCT) based navigation. Accuracy of pedicle screw placement was immediately checked by a final intra-operative cbCT Spin. RESULTS: Among 170 patients, group B included 91 patients and group S included 79 patients. Out of total 680 screws, 364 screws (group B) and 316 screws (group S) were placed. Patient's demographic data and distribution of screws showed no statistically significant difference. The accuracy showed no significant difference between both the groups (94.5% in group B and 94.3% in group S). CONCLUSION: Skin fixed DRF can serve as an alternate way for placement and avoids extra incision with similar accuracy in pedicle screw insertions with bone fixed DRF using intra-operative CT guided navigation in MIS TLIF.

Comparative study of the effect of N95 facemask and Powered Air-purifying Respirator (2 fans, N95 filter) on cardiovascular parameters of healthy individuals during exercise.

N95 masks filter 95% of the small particles and respiratory droplets (>0.3 µm diameter). Therefore, they are widely used both by general public and health workers during pandemic. When physical activity or exercise is performed wearing N95 mask, it induces hypercapnic environment. The heat burden is also increased leading to discomfort and reduced compliance. This study was done to compare physiological effects and subjective perceptions while wearing N95 mask and powered air-purifying respirator (PAPR) (2 fans, N95 filter) during incremental exercise. ECG, respiratory movement, SpO2, temperature inside the mask were recorded and perception of discomfort was also assessed. Heart rate variability (HRV) values during baseline were within normal limits in both the mask conditions signifying that cardiac autonomic tone is comparable. During incremental exercise, fall in SpO2 was significantly lesser in PAPR as compared to N95 mask at 60-70% and 70-80% of maximum achievable heart rate. The temperatures inside both the mask conditions were significantly higher than ambient temperature. The scores of humid, hot, breath resistance and fatigue were significantly lower in PAPR than N95 mask. In conditions where prolonged use of mask is required with strenuous physical exertion or exercise, PAPR could be preferred over N95 mask.

A Six-Year Clinical Profile of Distal Radius Fractures in a South Asian Population.

Background: The description, types and management of distal radius fractures have not been evaluated for a South Asian population. The aim of this study was to describe the clinical profile of distal radius fractures in adults over a 6-year period. Methods: The medical records of distal radius fracture patients, aged 18 years and above admitted between August 2014 and 2020 were assessed. Epidemiological profile, fracture classification, treatment and reasons for implant removal were assessed. Results: A total of 1066 distal radius fractures in 1005 inpatients were identified. The mean age was 42.1 ± 15.3 years (50.2 years [male] & 39.7 years [female]). A total of 65.5% patients sustained high-energy injury. 38.6% (n = 411) of fractures were classified as extra-articular AO-23-A, 24.3% (n = 259) as partially intra-articular AO-23-B and 39% (n = 416) as intra-articular AO-23-C. The treatment was non-surgical for 20.9% and surgical for 79.1% of cases. Plate fixation was the most frequently used surgical method followed by percutaneous pinning and external fixation. The proportion of patients treated by each modality remained constant based on a year-wise analysis of data. A total of 56 patients underwent implant removal, most commonly at the request of the patient. Conclusions: Our study is the longest study in a South Asian setting where the population is younger, with a male pre-ponderance, sustaining high-energy injury as compared to the literature. This can be attributed to our study population being inpatients only. As population-based fracture registry is not available in our country, hospital-based studies such as ours provide the best option to study fracture patterns, distribution and trends in treatment. Level of Evidence: Level IV.

Rapid, Economic, Acetic Acid Papanicolaou Stain (REAP): An Economical, Rapid, and Appropriate Substitute to Conventional Pap Stain for Staining Cervical Smears.

BACKGROUND: The unanimous method of screening cervical cancer is a cervical smear stained with Papanicolaou stain. However, in spite of the various modifications, the staining procedure takes 20 min and uses substantial amount of alcohol which is highly priced. The aim of the study was to assess and analyze the quality of staining of cervical smears stained with Rapid Economical Acetic acid Papanicolaou (REAP) as compared to conventional pap stain in order to establish REAP as an alternative to conventional pap stain. METHODS AND MATERIAL: In this prospective study, a total of two smears each were collected from 50 females who visited the gynecology outpatient department. One of the smears was stained with conventional pap and the other with REAP. The conventional pap and REAP smears were evaluated and compared for the quality of staining. RESULTS: The cervical smears stained with REAP showed optimal cytoplasmic and nuclear staining in 86% and 90% cases, respectively. The cytological findings and diagnosis of REAP stained smears correlated with their corresponding smears stained with conventional pap in 96% of cases. The turnaround time and cost per smear was much low for REAP as compared to conventional pap stain. CONCLUSION: The present study was able to establish REAP as an appropriate alternative to conventional pap stain. The staining by REAP was comparable to conventional pap stain.

Characterization of host response to Cryptococcus neoformans through quantitative proteomic analysis of cryptococcal meningitis co-infected with HIV.

Cryptococcal meningitis is the most common opportunistic fungal infection causing morbidity and mortality (>60%) in HIV-associated immunocompromised individuals caused by Cryptococcus neoformans. Molecular mechanisms of cryptococcal infection in brain have been studied using experimental animal models and cell lines. There are limited studies for the molecular understanding of cryptococcal meningitis in human brain. The proteins involved in the process of invasion and infection in human brain still remains obscure. To this end we carried out mass spectrometry-based quantitative proteomics of frontal lobe brain tissues from cryptococcal meningitis patients and controls to identify host proteins that are associated with the pathogenesis of cryptococcal meningitis. We identified 317 proteins to be differentially expressed (≥2-fold) from a total of 3423 human proteins. We found proteins involved in immune response and signal transduction to be differentially expressed in response to cryptococcal infection in human brain. Immune response proteins including complement factors, major histocompatibility proteins, proteins previously known to be involved in fungal invasion to brain such as caveolin 1 and actin were identified to be differentially expressed in cryptococcal meningitis brain tissues co-infected with HIV. We also validated the expression status of 5 proteins using immunohistochemistry. Overexpression of major histocompatibility complexes, class I, B (HLA-B), actin alpha 2 smooth muscle aorta (ACTA2) and caveolin 1 (CAV1) and downregulation of peripheral myelin protein 2 (PMP2) and alpha crystallin B chain (CRYAB) in cryptococcal meningitis were confirmed by IHC-based validation experiments. This study provides the brain proteome profile of cryptococcal meningitis co-infected with HIV for a better understanding of the host response associated with the disease.

Proteomics of human aqueous humor.

The aqueous humor is a colorless, transparent fluid that fills the anterior chamber of the eye. It plays an important role in maintaining the intraocular pressure and providing nourishment to the lens and cornea. The constitution of the aqueous humor is controlled by the blood-aqueous barrier. Though this ocular fluid has been extensively studied, its role in ocular physiology is still not completely understood. In this study, aqueous humor samples were collected from 250 patients undergoing cataract surgery, subjected to multiple fractionation strategies and analyzed on a Fourier transform LTQ-Orbitrap Velos mass spectrometer. In all, we identified 763 proteins, of which 386 have been identified for the first time in this study. Sorbitol dehydrogenase (SORD), filensin (BFSP1), and phakinin (BFSP2) are some of the proteins that have not been previously reported in the aqueous humor. Gene Ontology analysis revealed 35% of the identified proteins to be extracellular, with a majority of them involved in cell communication and signal transduction. This study comprehensively reports 386 novel proteins that have important potential as biomarker candidates for future research into personalized medicine and diagnostics aimed towards improving visual health.

Host response profile of human brain proteome in toxoplasma encephalitis co-infected with HIV.

BACKGROUND: Toxoplasma encephalitis is caused by the opportunistic protozoan parasite Toxoplasma gondii. Primary infection with T. gondii in immunocompetent individuals remains largely asymptomatic. In contrast, in immunocompromised individuals, reactivation of the parasite results in severe complications and mortality. Molecular changes at the protein level in the host central nervous system and proteins associated with pathogenesis of toxoplasma encephalitis are largely unexplored. We used a global quantitative proteomic strategy to identify differentially regulated proteins and affected molecular networks in the human host during T. gondii infection with HIV co-infection. RESULTS: We identified 3,496 proteins out of which 607 proteins were differentially expressed (≥1.5-fold) when frontal lobe of the brain from patients diagnosed with toxoplasma encephalitis was compared to control brain tissues. We validated differential expression of 3 proteins through immunohistochemistry, which was confirmed to be consistent with mass spectrometry analysis. Pathway analysis of differentially expressed proteins indicated deregulation of several pathways involved in antigen processing, immune response, neuronal growth, neurotransmitter transport and energy metabolism. CONCLUSIONS: Global quantitative proteomic approach adopted in this study generated a comparative proteome profile of brain tissues from toxoplasma encephalitis patients co-infected with HIV. Differentially expressed proteins include previously reported and several new proteins in the context of T. gondii and HIV infection, which can be further investigated. Molecular pathways identified to be associated with the disease should enhance our understanding of pathogenesis in toxoplasma encephalitis.