Fasting and post-glucose load measures of insulin resistance and risk of incident atrial fibrillation: The Cardiovascular Health Study.

BACKGROUND AND AIMS: Existing literature in individuals without diabetes has not demonstrated a relationship between IR and incident AF; however, data are limited and only fasting glucose measures of IR were assessed. We evaluated the relationship of both fasting and post-glucose load IR measures with the development of atrial fibrillation in nondiabetic older adults. METHODS AND RESULTS: Among Cardiovascular Health Study participants, a population-based cohort of 5888 adults aged 65 years or older enrolled in two waves (1989-1990 and 1992-1993), those without prevalent AF or diabetes and with IR measures at baseline were followed for the development of AF, identified by follow-up visit electrocardiograms, hospital discharge diagnosis coding, or Medicare claims data, through 2014. Fasting IR was determined by the homeostatic model of insulin resistance (HOMA-IR) and post-glucose load IR was determined by the Gutt index. Cox proportional hazards models were used to determine the association of IR with risk of AF. Analyses included 3601 participants (41% men) with a mean age of 73 years. Over a median follow-up of 12.3 years, 1443 (40%) developed AF. After multivariate adjustment, neither HOMA-IR nor the Gutt index was associated with risk of developing AF [hazard ratios (95% confidence intervals): 0.96 (0.90, 1.03) for 1-SD increase in HOMA-IR and 1.03 (0.97, 1.10) for 1-SD decrease in the Gutt index]. CONCLUSIONS: We found no evidence of an association between either fasting or post-glucose load IR measures and incident AF.

Evolving management of insulinoma: Experience at a tertiary care centre.

BACKGROUND & OBJECTIVES: Since our previous study in 2006, several new modalities for localization of cause of endogenous hyperinsulinemic hypoglycaemia such as multiphasic computed tomography (CT), multiphasic magnetic resonance imaging (MRI), endoscopic ultrasound (EUS), intraoperative ultrasound, and intra-arterial calcium infusion with arterial stimulation venous sampling (ASVS) have become available. Therefore, to evaluate the relative usefulness of various imaging modalities to guide future management in terms of diagnosis and patient care, we analyzed presentation and management of patients of endogenous hyperinsulinemic hypoglycaemia. METHODS: In this retrospective study, medical records of patients admitted with endogenous hyperinsulinemic hypoglycaemia were retrieved. Data pertaining to clinical features, diagnosis, imaging, surgery and patient outcome were extracted. The localization of insulinoma by preoperative imaging techniques was compared with the findings at surgery to assess the accuracy of localization. RESULTS: Fasting hypoglycaemia was present in all, and post-prandial hypoglycaemia (plasma glucose ≤50 mg/dl within four hours of meal) in 25.8 per cent. Mean duration of symptoms before reaching a diagnosis of hyperinsulinemic hypoglycaemia was 3.9 years. Mean duration of provocative fast was 21.8 h (range 6-48 h). Among the currently used imaging modalities, the sensitivity of localizing tumour was 79.3 per cent for multiphasic CT, 85 per cent for multiphasic MRI and 95 per cent for EUS. EUS detected tumour missed by both CT and MRI. All, except one of the operated patients, were cured by surgery. INTERPRETATION & CONCLUSIONS: Our results suggest that patients with insulinoma have a varied presentation. Multiphasic contrast-enhanced MRI/CT scan, EUS and ASVS may be complimentary in pre-operative localization.

Clinico-radiological Correlation of Bone Changes in Leprosy Patients Presenting with Disabilities/Deformities.

Leprosy is a medical - social disease, it is associated with stigma in the society due to the resulting deformities in some persons. Although stigma has decreased after the widespread use of MDT, some disabilities do occur which are mostly due to late initiation of treatment and inappropriate care. Besides the nerve and skin involvement bone changes have been reported to be common in leprosy. These bony changes need to be understood in the present MDT era specially in the context of clinical spectrum and duration of disease/ deformities. Fifty clinically diagnosed and histologically classified leprosy patients with deformities/ disabilities of either hands/feet/face who attended the OPD of Department of Dermatology, Venereology and Leprosy, Government Medical College, Amritsar were examined and evaluated in the study. Radiological examination of hands, feet and skull was done in each case and the bone changes in hands and feet; and skull and paranasal sinus changes were correlated with clinical parameters. Bone changes were observed in 90% of cases radiologically. Specific bone changes in hands and feet, non-specific bone changes in hands, feet, skull and paranasal sinuses were seen in 66%, 82% and 32% of cases respectively. Common specific bone changes in hands and feet observed were primary periostitis (14%), honey combing (46%), bone cyst (36%), thinning and irregularity of cortex (28%) and area of bone destruction (20%); Among the non-specific bone changes observed were contracted fingers/claw hands/claw toes (64%) and absorption of terminal phalanges (40%). The maxillary sinus, and paranasal sinus changes were the most common radiological findings observed in skull. The study of the radiological changes may help the clinicians to understand the gravity of the situation and undertake steps for timely prevention of permanent loss of function and the occurrence of deformities and disabilities.

Classifying the severity of acute pancreatitis: towards a way forward.

BACKGROUND: The recent development of two different severity classifications for acute pancreatitis has appropriately raised questions about which should be used. The aim of this paper is to review the two new severity classifications, outline their differences, review validation studies, and identify gaps in knowledge to suggest a way forward. METHODS: A literature review was performed to identify the purposes and differences between the classifications. Validation studies and those comparing the two different classifications were also reviewed. RESULTS: The Revised Atlanta Classification (RAC) and the Determinants Based Classification (DBC) both rely on assessment of local and systemic factors. The differences between the classifications provides opportunities for further research to improve the accuracy and utility of severity classification. This includes understanding how best to tailor severity classification to setting (e.g. secondary or tertiary hospital) and purpose (e.g. clinical management or research). A key difference is that the RAC does not consider infected pancreatic necrosis an indicator of severe disease. There is also the need to develop methods for the accurate non-invasive diagnosis of infected necrosis and evaluation of the characteristics of organ dysfunction in relation to severity and outcome. CONCLUSION: Further improvement in severity classification is possible and research priorities have been identified. For now, the decision as to which classification to use should be on the basis of setting, validity, accuracy, and ease of use.

Prognostic significance of soft tissue deposits in head and neck squamous cell carcinoma: a systematic review and meta-analysis.

Soft tissue deposits, also known as tumour deposits (TDs), have not been studied well in head and neck squamous cell carcinoma (HNSCC) and are not included in any of the staging systems or treatment guidelines. The aim of this systematic review was to determine the prevalence and prognostic implications of TDs in patients with HNSCC. This systematic review of the literature was conducted following the PRISMA guidelines. The PubMed, Embase, and Scopus electronic databases were searched for relevant studies, from inception to August 2022. Although 14 studies qualified for inclusion, only eight were finally included in the review due to the considerable overlap of patients in several studies. Data from 7127 patients were analysed. The pooled prevalence of TDs was 21% (95% confidence interval (CI) 9-33%). The presence of TDs was adversely associated with overall survival and disease-free survival, with hazard ratios of 2.08 (95% CI 1.60-2.70) and 2.56 (95% CI 1.97-3.32), respectively. TDs are detected in a significant number of patients with HNSCC and adversely affect survival. Longitudinal prospective studies are needed to evaluate the prognostic implications of TDs in HNSCC for their potential role in cancer staging and adjuvant treatment planning.

Intra-operative pain and patient satisfaction during lichtenstein repair under local anesthesia versus spinal anesthesia: an open-label randomized controlled trial.

PURPOSE: To compare pain during surgery among patients undergoing Lichtenstein inguinal hernia repair (LIHR) under local anaesthesia (LA) and spinal anaesthesia (SA). METHOD: Patients were randomized to undergo LIHR under LA or SA. Both intra-operative and postoperative pain was measured by NRS (numerical rating scale). Postoperative pain was managed similarly in both groups using intravenous diclofenac and paracetamol. Postoperative recovery, time to discharge, and early complications were recorded. Postoperative pain was assessed at 2, 6 and 24 h from the time of skin incision. Patient satisfaction was recorded on 5-point Likert scale 24 h after surgery. RESULTS: Data of 30 patients of each group were analyzed. All patients successfully underwent operation using anaesthesia technique allocated. Median intra-operative pain was 0 (0,3) in SA and 2.5 (0,5) in LA group. In SA group, intra-operative pain did not exceed NRS 3, while in LA, pain greater than NRS 3 was reported in 30% patients. No patient required tramadol in either group during postoperative period. Minor postoperative complications were reported 9/30 (30%) in SA compared to 1/30 (3.33%) in LA group. The satisfaction rate was 67% in LA group, whereas 37% in SA group. CONCLUSION: LA should be strongly considered for all patients with unilateral inguinal hernia undergoing open repair. In spite of a slightly more severe pain during surgery, patient satisfaction was higher using LA. TRIAL REGISTRATION: This study was conducted as a part of a postgraduate thesis research work. The protocol was submitted to the University of Delhi after approval of the IEC. Registration with the Clinical Trials Registry of India was not successfully done.

Chronic groin pain in Desarda versus Lichtenstein hernia repair - a randomised controlled study.

BACKGROUND: Chronic pain after inguinal hernia repair is a common complication. This study compared the difference between Desarda repair and Lichtenstein repair for inguinal hernia in chronic groin pain. METHODS: One hundred patients with unilateral uncomplicated inguinal hernia were randomised to either Desarda repair (n = 50) or Lichtenstein repair (n = 50) under local anaesthesia and were evaluated for pain postoperatively. Operative time, surgical complications, time to return to normal gait and work, and overall patient satisfaction were recorded. The patient was blinded to the procedure. Any pain at three months (numerical rating scale 1 or more) was considered chronic pain. RESULTS: Mean operation time was approximately 5 minutes less for Desarda (p = 0.33). There was no significant difference in terms of pain level postoperatively between Lichtenstein and Desarda groups. Twenty-two (44%) patients in the Lichtenstein group had chronic pain, and twenty-one (45.7%) patients had chronic pain in the Desarda group (p = 0.871). No significant difference was observed in haematoma formation, wound infection, recurrence rate, seroma, or foreign body sensation. The mean time for patients to return to normal gait was approximately 0.5 day earlier for the Desarda group (p = 0.29). The mean time for patients to return to normal work was comparable (p = 0.99). Desarda group had a slightly higher satisfaction rate than the Lichtenstein group (9.1%). CONCLUSION: Desarda repair is not inferior to Lichtenstein repair in the short-term concerning complications or pain.

Incidental congenital transmesenteric hernia in an adult.

Transmesenteric hernia is a rare type of internal hernia. We report a case of a 45 year old lady who was found to have an incidental congenital transmesenteric hernia of ileum caused by a congenital mesenteric defect during radical cystectomy done for muscle invasive transitional cell carcinoma of urinary bladder.

Acute intestinal obstruction: an unusual complication of mucocele of appendix.

A rare case of intestinal obstruction due to compression of ileocecal junction by mucocele of appendix is presented. Imaging with ultrasound or computed tomography (CT) is useful in establishing preoperative diagnosis. Avoidance of rupture of during appendicectomy is critical in preventing potential complication of pseudomyxoma peritonei.

Reference Charts of Fetal Biometric Parameters at Different Gestational Age Groups in Indian Population.

To develop, a reference charts of fetal abdominal circumference and femur length in normal pregnant women by using ultrasonography for Indian population. Further comparison of our findings with data derived from different population. This retrospective cross-sectional study included 300 normal singleton pregnancies and was carried out in the department of Anatomy, All India Institute of Medical Sciences, Jodhpur (Rajasthan), India from September 2017 to April 2019. Ultrasonography measurements included Abdominal circumference (AC) and Femur length (FL). Reference charts with mean AC and FL for corresponding Gestational age (GA) in weeks were developed. Also reference centiles (10th, 50th, 90th and 95th) were derived from this model and compared with similar studies done on different population. There was no statistically significant difference in age distribution of pregnant women (p=0.87). Both AC and FL were found to have statistically significant linear relationship with advancing gestational age (p=0.0005 & p=0.0003 respectively). There is significant difference observed between the values obtained in present study with studies concluded on Chinese and European population. Measurement of AC and FL are used to predict gestational age of fetus by using various regression formulae, also AC is known to be good predictor of nutritional status of fetus in utero. A separate chart is required for every different population because ethnicity, nutrition and environmental factor can have impact on normal values. Therefore, a reference chart for these parameters according to Indian population standards is essential to avoid misinterpretation of data. This would help to avoid misdiagnosis of intrauterine growth retardation or macrosomia during prenatal and perinatal period.

Estimation of Fetal Weight: An Ultrasonography Study in Indian Population.

To create a reference chart for estimated fetal weight (EFW) in normal pregnancy for use in Indian population and compare it with reference chart from other population. This retrospective cross-sectional study included 300 normal singleton pregnancies coming for routine antenatal ultrasonography examination and was carried out at All India Institute of Medical Sciences, Jodhpur from September 2017 to April 2019. Ultrasonographic measurements included fetal biparietal diameter (cm), head circumference (cm), abdominal circumference (cm) and femur length (cm). Estimated fetal weight was calculated by using Hadlock algorithm which is already fed into ultrasonography machine. Reference chart with mean EFW for corresponding Gestational age (GA) in weeks was developed. Also Reference centiles (10th, 50th, 90th and 95th) were derived from this model. There was no statistically significant difference in age distribution of pregnant women (p=0.87). Statistically significant linear relationship found between EFW and advancing gestational age (p=0.0004). Maximum gain in EFW (34.05%) was observed after second trimester (28 week). Maximum and minimum fetal weight at 38 weeks of GA in our study found to be 3389 grams and 2567 grams respectively, which has significant difference. This could be due to huge difference in socio-economic and nutritional status among Indian population which might have impacted on maternal and fetal health. Estimated fetal weight was found to be at lower range in Indian population compared to reference chart developed into western population. Fetal weight to their corresponding GA is an important factor in determining growth and development in fetus. In normally developing fetus the EFW has linear correlation with advancing GA. A separate reference chart is required for every different population because ethnicity, nutrition and environmental factor can have impact on normal EFW values. This would help to avoid misdiagnosis of intrauterine growth retardation or macrosomia in fetuses and hence unnecessary medical interventions can be prevented during prenatal and perinatal period.

Behavioral and neurobiological characteristics influencing social hierarchy formation in female cynomolgus monkeys.

Socially housed monkeys have been used as a model to study human diseases. The present study examined behavioral, physiological and neurochemical measures as predictors of social rank in 16 experimentally naïve, individually housed female cynomolgus monkeys (Macaca fascicularis). The two behavioral measures examined were novel object reactivity (NOR), as determined by latency to touch an opaque acrylic box placed in the home cage, and locomotor activity assessed in a novel open-field apparatus. Serum cortisol concentrations were evaluated three times per week for four consecutive weeks, and stress reactivity was assessed on one occasion by evaluating the cortisol response to adrenocorticotropic hormone (ACTH) following dexamethasone suppression. Measures of serotonin (5-HT) function included whole blood 5-HT (WBS) concentrations, cerebrospinal fluid (CSF) concentrations of the 5-HT metabolite 5-hydroxyindoleacetic acid (5-HIAA) and brain 5-HT transporter (SERT) availability obtained using positron emission tomography (PET). After baseline measures were obtained, monkeys were assigned to four social groups of four monkeys per group. The two measures that correlated with eventual social rank were CSF 5-HIAA concentrations, which were significantly higher in the animals who eventually became subordinate, and latency to touch the novel object, which was significantly lower in eventual subordinate monkeys. Measures of 5-HT function did not change as a consequence of social rank. These data suggest that levels of central 5-HIAA and measures of novel object reactivity may be trait markers that influence eventual social rank in female macaques.

Health GIS and HIV/AIDS studies: Perspective and retrospective.

GIS (Geographic Information System) is a useful tool that aids and assists in health research, health education, planning, monitoring and evaluation of health programmes that are meant to control and eradicate certain life threatening diseases and epidemics. HIV/AIDS is one such epidemic that poses a serious challenge and threatens the overall human welfare. This communication is an attempt to link and understand the health scenario in a GIS context with emphasis on HIV/AIDS. Various GIS based functionalities for health studies and their scope in analyzing and controlling epidemiological diseases are explored. Overall scenario of the spread of HIV/AIDS around the world is presented along with the Indian perspective. Finally, we conclude with the general management problems, issues and challenges related to HIV/AIDS prevailing in India.

Incidental Coronary Artery Calcification Seen on Low-Dose Computed Tomography Is a Risk Factor for Obstructive Coronary Artery Disease in Patients Undergoing Liver Transplant.

Incidental arterial calcification (Ca) on low-dose computed tomography (CT) prior to liver transplant (LT) may help identify those at risk for obstructive coronary artery disease (CAD). A single-center retrospective study of 358 consecutive patients who had undergone LT was performed. Of the 296 patients who met inclusion criteria, 193 patients (65.2%) had CT Ca. Aortic Ca was seen in 116 (39.2%), coronary Ca in 141 (47.6%), and peripheral Ca in 8 patients (2.7%). Patients with coronary Ca were assigned ordinal coronary artery Ca scores and classified as mild, moderate, and severe. All-cause mortality was higher in patients with Ca in any location (14.5% vs 6.8%, P = .05). Of the patients who underwent coronary angiography, those with obstructive CAD were more likely to have aortic and coronary Ca than patients with nonobstructive or no CAD (85.7% vs 50.0%, P = .02 and 92.9% vs 37.9%, P = < .001, respectively). Severe coronary artery Ca scores were more frequent in patients with obstructive CAD (35.7% vs 0%, P < .001). Any severity coronary Ca had an odds ratio of 11.57 (95% CI, 1.61-244.92; P = .04) for obstructive CAD. In conclusion, incidental coronary Ca seen on low-dose CT is a risk factor for obstructive CAD in patients undergoing LT.