Wide-awake local anesthesia and no tourniquet (WALANT) in upper limb fractures.

Wide-awake local anesthesia and no tourniquet (WALANT), first used for hand surgery, has been sparingly described for use in fracture fixation of the upper limb. We present our experience using this technique. 26 patients with upper limb fractures (3 distal radius, 6 radial shaft, 11 ulnar shaft, and 6 olecranon fractures) were operated on using WALANT by three orthopedic surgeons. We used 35-40ml of 2% Lignocaine with 1:80000 Adrenaline(7mg/kg) diluted with normal saline. Numeric Pain Rating (NPR) scoring was done during injection and per-operatively, and the Likert scale was used for the surgeon's satisfaction. The average NPR score was reported as 0.65 (1-3) during injection and 0.15 (0-2) preoperatively. All three surgeons reported excellent satisfaction in all the cases operated on. No complication occurred due to anesthesia. WALANT is a much simpler option and can be safely used in place of general anesthesia or regional blocks for fixation of fractures of the upper limb, with added advantages of no need for a tourniquet and better intraoperative assessment of fracture fixation.

Urinary Markers of Fibrosis and Risk of Cardiovascular Events and Death in Kidney Transplant Recipients: The FAVORIT Trial.

Cardiovascular risk remains high in kidney transplant recipients (KTRs) despite improved kidney function after transplant. Urinary markers of kidney fibrosis and injury may help to reveal mechanisms of this risk. In a case-cohort study among stable KTRs who participated in the FAVORIT trial, we measured four urinary proteins known to correlate with kidney tubulointerstitial fibrosis on biopsy (urine alpha 1 microglobulin [α1m], monocyte chemoattractant protein-1 [MCP-1], procollagen type I [PINP] and type III [PIIINP] N-terminal amino peptide) and evaluated associations with cardiovascular disease (CVD) events (n = 300) and death (n = 371). In adjusted models, higher urine α1m (hazard ratio [HR] per doubling of biomarker 1.40 [95% confidence interval [CI] 1.21, 1.62]), MCP-1 (HR 1.18 [1.03, 1.36]), and PINP (HR 1.13 [95% CI 1.03, 1.23]) were associated with CVD events. These three markers were also associated with death (HR per doubling α1m 1.51 [95% CI 1.32, 1.72]; MCP-1 1.31 [95% CI 1.13, 1.51]; PINP 1.11 [95% CI 1.03, 1.20]). Higher concentrations of urine α1m, MCP-1, and PINP may identify KTRs at higher risk for CVD events and death. These markers may identify a systemic process of fibrosis involving both the kidney and cardiovascular system, and give new insights into mechanisms linking the kidney with CVD.

DPD epitope-specific glutamic acid decarboxylase (GAD)65 autoantibodies in children with Type 1 diabetes.

AIM: To study whether DPD epitope-specific glutamate decarboxylase autoantibodies are found more frequently in children with milder forms of Type 1 diabetes. METHODS: We prospectively evaluated 75 children with new-onset autoimmune Type 1 diabetes, in whom we collected demographic, anthropometric and clinical data and measured islet autoantibodies. Glutamate decarboxylase 65 autoantibody-positive samples were analysed for epitope specificities using recombinant Fab against the DPD-defined epitope of glutamate decarboxylase 65. RESULTS: After adjustment for age, positive DPD epitope recognition was significantly associated with higher C-peptide levels at onset (P = 0.02, r2 =0.21, n = 35), and high DPD recognition in the highest quartile tended to be associated with HbA1c ≤ 53 mmol/mol (7%) at the last follow-up [mean (sd) follow-up 1.3 (0.4) years; P = 0.07; for the model, P = 0.044, n = 30)]. Age- and sex-adjusted BMI percentile was significantly correlated with recognition of the DPD-defined epitope (P < 0.03, r2 =0.14, n = 34), but this correlation was driven by the older age group (age ≥ 10 years; P = 0.016, r2 =0.27, n = 21) and was not significant in younger children (P = 0.93, n = 13). There were no independent associations with sex, race/ethnicity, diabetic ketoacidosis, HbA1c , HLA DR3-DQ2/DR4-DQ8 or autoantibody number. CONCLUSIONS: Our findings suggest that recognition of the DPD-defined glutamate decarboxylase 65 autoantibody epitope at Type 1 diabetes onset is directly associated with ß-cell function, BMI and age, which supports the hypothesis that immunological factors contribute to the clinical heterogeneity of Type 1 diabetes. Larger studies relating epitope-specific glutamate decarboxylase 65 autoantibody to clinical phenotype in children with Type 1 diabetes are warranted.

Familial progressive hyper- and hypopigmentation and malignancy in two families with new mutations in KITLG.

BACKGROUND: Familial progressive hyper- and hypopigmentation (FPHH) is an autosomal dominant skin condition presenting in childhood with generalized macular dyspigmentation, usually reported in patients of East Asian origin. It overlaps phenotypically with other dyschromatoses, but can now be distinguished by mutations in the KIT ligand gene (KITLG). AIM: We report two unrelated white families with similar phenotypic presentations of FPHH developing in early childhood in several generations. METHODS: Sanger sequencing of the exons and flanking introns of KITLG was performed. RESULTS: This identified a new heterozygous missense mutation in each family (p.Thr34Asn and p.Val37Gly, respectively). Of the six affected individuals examined by us, two had cancer: a 62-year-old man in family 1 had developed two primary melanomas and a pharyngeal carcinoma, and a 42-year-old woman in family 2 had developed thyroid carcinoma. All had unusually sparse lateral eyebrows, a finding not previously reported in this condition. CONCLUSIONS: We summarize the genetic spectrum of the dyschromatoses and discuss a possible increased risk of malignancy in FPHH.

Outcome analysis of cubital tunnel decompression.

BACKGROUND: Cubital tunnel decompression is a commonly undertaken upper limb procedure. Most studies compare the different techniques of decompression; however, only a few have specifically investigated the outcome of ulnar nerve decompression. AIM: The aim of this study was to investigate the outcome of ulnar nerve decompression following cubital tunnel syndrome. METHODS AND RESULTS: A total of 174 ulnar nerve decompression cases were identified from the upper limb surgery database with complete data available for 136 cases. Simple decompression was performed in 110 (80.88%) cases, and in 26 (19.12%), anterior subcutaneous transposition was also supplemented. These operations were performed at three different hospitals by surgeons of different levels of experience. The most common cause of cubital tunnel syndrome was idiopathic. The outcome was satisfactory in 86% of cases. No obvious association was demonstrated between the outcome of surgery and duration of symptoms, presence of co-morbidities or the type of surgery performed. CONCLUSION: This is the largest outcome analysis of the results of ulnar nerve decompression at the elbow. Good results following nerve decompression were attained in 86% of cases without any significant effect of duration of symptoms or co-morbidities on the outcome of surgery. It is hoped that the findings of the current study will help general practitioners, junior doctors and surgeons in their management and pre-operative consultation with patients having cubital tunnel syndrome.

Correlation of Radiographic Mental Foramen Position and Occulusion in Three Different Indian Populations.

BACKGROUND: The knowledge of the position of the mental foramen (MF) is important for administering local anaesthesia for diagnostic, surgical or operative procedures. AIMS: To determine the shape, position, symmetry of MF and its continuity with the inferior dental canal (IDC) on a digital panoramic view and to find its correlation with Angle's molar relations in three Indian subpopulations. The study also determines the correlation of inter-foramen distance in both genders of three Indian subpopulations. SUBJECTS AND METHODS: One hundred and twenty digital panoramic radiographs were evaluated from three Indian subpopulations (Punjab, Rajasthan and Northeast [NE]). The assessment of occlusion was based on Angle's molar relationships. The data obtained were statistically analysed. RESULTS: The commonest position of the MF in the Rajasthan and NE populations was position 4 bilaterally, while in the Punjab population, it was position 3 on the right and position 4 on the left side. The majority of the MF was round in shape followed by oval. The mean distance between two MF was highest among the Punjab male population and least among the NE female population. The most frequent pattern of MF continuity with IDC was diffuse in Rajasthan population, separated in NE and continuous in Punjab. Correlation between Angle's molar relation with MF position was significant for Classes I and II but not for Class III. Correlation of inter-foramen distance between genders was highly significant in the NE and Punjab populations. CONCLUSION: The commonest MF position was aligned with the 1st premolar and between the 1st and 2nd premolar.

Major ethnic group differences in breast cancer screening uptake in Scotland are not extinguished by adjustment for indices of geographical residence, area deprivation, long-term illness and education.

BACKGROUND: Breast cancer screening data generally show lower uptake in minority ethnic groups. We investigated whether such variations occur in Scotland. METHODS: Using non-disclosive computerised linkage we combined Scottish breast screening and Census 2001 data. Non-attendance at first breast-screening invitation (2002-2008) was compared between 11 ethnic groups using age-adjusted risk ratios (RR) with 95% confidence intervals (CI), multiplied by 100, using Poisson regression. RESULTS: Compared with the White Scottish (RR=100), non-attendance was similar for Other White British (99.5, 95% CI 96.1-103.2) and Chinese (112.8, 95% CI 96.3-132.2) and higher for Pakistani (181.7, 95% CI 164.9-200.2), African (162.2, 95% CI 130.8-201.1), Other South Asian (151.7, 95% CI 118.9-193.7) and Indian (141.7, 95% CI 121.1-165.7) groups. Adjustment for rural vs urban residence, long-term illness, area deprivation and education, associated with risk of non-attendance, increased the RR for non-attendance except for Pakistani women where it was modestly attenuated (RR=164.9, 149.4-182.1). CONCLUSION: Our data show important inequality in breast cancer screening uptake, not attenuated by potential confounding factors. Ethnic inequalities in breast screening attendance are of concern especially given evidence that the traditionally lower breast cancer rates in South Asian groups are converging towards the risks in the White UK population. Notwithstanding the forthcoming review of breast cancer screening, these data call for urgent action.

Terahertz response and colossal Kerr rotation from the surface states of the topological insulator Bi2Se3.

We report the THz response of thin films of the topological insulator Bi2Se3. At low frequencies, transport is essentially thickness independent showing the dominant contribution of the surface electrons. Despite their extended exposure to ambient conditions, these surfaces exhibit robust properties including narrow, almost thickness-independent Drude peaks, and an unprecedentedly large polarization rotation of linearly polarized light reflected in an applied magnetic field. This Kerr rotation can be as large as 65° and can be explained by a cyclotron resonance effect of the surface states.

Linkage of data in the study of ethnic inequalities and inequities in health outcomes in Scotland, New Zealand and The Netherlands: insights for global study of ethnicity and health.

Reducing inequalities in health is a global priority. An essential tool in achieving this reduction is the ability to provide valid measurements of inequalities, which are comparable over time and ultimately across countries and continents. With valid data a true understanding of inequalities can be ascertained, which can begin to inform effective legislation and policy. In this workshop, the speakers described in three different countries, Scotland, New Zealand and The Netherlands, how record linkage has been used to link ethnic status to health and health care measures and so to determine ethnic inequalities in health with the ultimate aim of reducing these inequalities.

Nocardia nova mycetoma over forehead in a lepromatous leprosy patient.

We present a case of a 31-year-old male, a known patient with lepromatous leprosy with a type 2 lepra reaction, who presented with a slowly growing asymptomatic swelling with multiple discharging sinuses over the forehead that developed over 6 months. Smears of the serosanguinous discharge on Gram staining showed Gram-positive branching filamentous bacilli, which on culture on blood agar showed chalky-white colonies. Histology of the lesion showed suppurative granulomas with polymorphs surrounding characteristic grains. The isolate was identified as Nocardia nova by gene sequencing and the patient was started on combined antibiotic therapy that resulted in complete resolution of the infection in six months. To the best of our knowledge, this is the first report of mycetoma related to Nocardia nova in association with leprosy.

COVID-19 vaccination in the Indian blood donors: Adjudging the impact on the deferral period.

The only efficacious way to provide people with herd immunity against the novel corona virus [nCoV] is to administer an appropriate vaccine and help check the current pandemic. With the genetic sequence data of the nCoV already available since January 10, 2020, leading pharmaceutical companies, world over, in turn, have started working on the clinical trials to produce vaccines against this nCoV. In fact, many vaccines under the Phase III trial have claimed to demonstrate their efficacy to be as high as 95% against the nCoV. In January, the central drugs standard control organization, India had granted the emergency-use authorization [EUA] to two vaccines namely, Covishield (live vaccine, Oxford-AstraZeneca, United Kingdom being manufactured by the Serum Institute of India, Pune) and Covaxin (inactivated vaccine, Bharat Biotech, India). Although, most of the countries offer no deferral period for the donors who have been administered an inactivated vaccine against this nCoV. However, the national blood transfusion council of India has recently recommended a donor deferral period of 28 days from the last dose of vaccination. This could essentially lead to a massive loss of eligible blood donors and jeopardize the already disrupted blood supply management due to the COVID-19 outbreak. The authors, herein, propose a thorough redefining of this deferral period post-vaccination amongst the Indian blood donors.

COVID-19 vaccination: The impact on the selection criteria of the convalescent plasma donors.

Clinical management protocols for COVID-19 are evolving rapidly as more information about the epidemiology and pathophysiological changes in COVID-19 become available. However, no definite treatment of COVID-19 has been found till date. The COVID-19 convalescent plasma (CCP) therapy has emerged as an important investigational therapy in the management of COVID-19 patients. Additionally, the regulatory agencies, in particular, the Indian blood transfusion council must release some interim recommendations for the blood centres on the CCP blood donor eligibility criteria after COVID-19 vaccination. More clinical trials are needed to know the efficacy of the CCP harvested from COVID-19 recovered individuals who have been vaccinated against those COVID-19 recovered individuals who are not vaccinated to understand the vaccine impact on the IgG titres of anti-SARS-CoV-2 antibodies.

Percutaneous balloon mitral valvuloplasty with bilateral carotid protection in 2 cases of left atrial thrombus.

We present 2 cases of mitral stenosis with left atrial thrombus who underwent Balloon Mitral Valvotomy with bilateral carotid protection using SpiderFX, distal protection devices to minimize the risk of neuroembolic stroke. One patient was critical MS in congestive heart failure with a highly mobile left atrial appendage clot (LAA) and the second patient was a young female who declined surgery and had an LAA clot which did not respond to warfarin therapy.

Pharmacist involvement to improve patient outcomes in lower gastrointestinal surgery: a prospective before and after study.

Background Enhanced recovery pathways were first introduced in the UK in 2002 (Enhanced Recovery Partnership Programme in Delivering enhanced recovery-helping patients to get better sooner after surgery. Department of Health, London, 2010). The aims of such pathways are to reduce patient length of stay whilst still providing high quality of care. Objectives To evaluate the impact of pharmacist involvement in enhanced recovery pathways. Setting A large 1200 bed tertiary hospital in the North of England. Methods The pre-post study included all patients admitted for major colorectal surgery during the period 2013-2016. Baseline data were collected on all patients seen pre-operatively in a nurse-led pre-admission clinic. The intervention was introduced where a dedicated surgical pharmacist pre-operatively reviewed patients from the time they were listed for surgery until discharge with a focus on medicines optimisation. Main outcome measure The primary outcome measures were length of stay along with the type and number of post-operative complications. Results 100 patients were included in this study, with 50 patients in the baseline group and 50 patients in the intervention group. There was a significant reduction in the median length of stay (baseline group-10.5 days; intervention group-7.5 days; P < 0.001). The total number of complications was also less in the intervention group (baseline group-125; intervention group-75; P > 0.05) as was the number of patients whom had no complications (P > 0.05). Conclusions Active pharmacist involvement in enhanced recovery protocols is associated with a significantly reduced median length of stay as well as an overall reduction in the total number of post-operative complications.

Dynamic Contrast-Enhanced MRI to Differentiate Parotid Neoplasms Using Golden-Angle Radial Sparse Parallel Imaging.

BACKGROUND AND PURPOSE: Conventional imaging frequently shows overlapping features between benign and malignant parotid neoplasms. We investigated dynamic contrast-enhanced MR imaging using golden-angle radial sparse parallel imaging in differentiating parotid neoplasms. MATERIALS AND METHODS: For this retrospective study, 41 consecutive parotid neoplasms were imaged with dynamic contrast-enhanced MR imaging with golden-angle radial sparse parallel imaging using 1-mm in-plane resolution. The temporal resolution was 3.4 seconds for 78.2 seconds and 8.8 seconds for the remaining acquisition. Three readers retrospectively and independently created and classified time-intensity curves as follows: 1) continuous wash-in; 2) rapid wash-in, subsequent plateau; and 3) rapid wash-in with washout. Additionally, time-intensity curve-derived semiquantitative metrics normalized to the ipsilateral common carotid artery were recorded. Diagnostic performance for the prediction of neoplasm type and malignancy was assessed. Subset multivariate analysis (n = 32) combined semiquantitative time-intensity curve metrics with ADC values. RESULTS: Independent time-intensity curve classification of the 41 neoplasms produced moderate-to-substantial interreader agreement (κ = 0.50-0.79). The time-intensity curve classification threshold of ≥2 predicted malignancy with a positive predictive value of 56.0%-66.7%, and a negative predictive value of 92.0%-100%. The time-intensity curve classification threshold of <2 predicted pleomorphic adenoma with a positive predictive value of 87.0%-95.0% and a negative predictive value of 76.0%-95.0%. For all readers, type 2 and 3 curves were associated with malignant neoplasms (P < .001), and type 1 curves, with pleomorphic adenomas (P < .001). Semiquantitative analysis for malignancy prediction yielded an area under the receiver operating characteristic curve of 0.85 (95% CI, 0.73-0.99). Combining time-to-maximum and ADC predicts pleomorphic adenoma better than either metric alone (P < .001). CONCLUSIONS: Golden-angle radial sparse parallel MR imaging allows high spatial and temporal resolution permeability characterization of parotid neoplasms, with a high negative predictive value for malignancy prediction. Combining time-to-maximum and ADC improves pleomorphic adenoma prediction compared with either metric alone.

Anaesthetic management of a parturient with severe kyphoscoliosis.

Use of neuraxial block in a patient with severe kyphoscoliosis is controversial. We describe the anaesthetic management by spinal anaesthesia of a parturient with severe kyphoscoliosis in obstructed labour. The perioperative course was uneventful. We suggest that a patient with severe kyphoscoliosis may be successfully managed by spinal anaesthesia for caesarean section.

Factors Affecting Insulin Resistance and Its Relation to Vitamin D Status and Clinical Nutritional Parameters in Dialysis Patients: A Single-center Indian Study.

The aim of this study was to measure insulin resistance (IR) in dialysis patients and its relation to Vitamin D status and nutritional parameters. We included patients on maintenance dialysis, both hemodialysis and peritoneal dialysis (HD and PD). IR was measured by homeostatic model assessment (HOMA)-IR index defined as fasting serum insulin (µU/L) × fasting blood sugar (mmol/L)/22.5. Baseline Vitamin D levels were measured by chemiluminescence immunoassay (CLIA) method. HOMA-IR index correlated with nutritional parameters such as 7-point subjective global assessment (SGA) and anthropometric measures, for example, body fat percentage, lean body weight (LBW), mid-arm circumference (MAC), and mid-arm muscle circumference (MAMC). A total of 55 patients were studied, of them 74.55% were male with mean age of the study population being 37.44 ± 14.96 years. The prevalence values of Vitamin D deficiency <30 ngm/ml, <20 ngm/ml, and <10 ngm/ml levels were 96.36%, 70.91%, and 23.64%, respectively. Mean HOMA-IR index was 3.14 ± 3.86. The correlation of HOMA-IR with Vitamin D was negative (r = -0.140, 95% confidence interval [CI] = -0.397-0.138 and P = 0.309); however, in subgroup analysis, patients with Vitamin D level <20 ng/ml had significantly high IR compared to those with Vitamin D >20 ng/ml, i.e., 3.74 ± 4.37 and 1.67 ± 1.47, respectively (P = 0.018). The other measured parameter which had a significant positive correlation with IR was serum uric acid (r = 0.303, 95% CI = 0.021-0.534, and P = 0.025). In nutritional assessment, body mass index, MAC, and MAMC had statistically significant positive correlation with HOMA-IR index (P ≤ 0.001, 0.004, and 0.004, respectively) unlike SGA (P = 0.480). The mode of dialysis did not have a significant effect on IR (HD vs. PD, P = 0.227). The majority of the patients on maintenance dialysis are Vitamin D deficient. Low Vitamin D level, especially <20 ng/ml, muscle mass, and high serum uric acid level are likely to have more IR in dialysis-dependent patients.

The effect of breastmilk and saliva combinations on the in vitro growth of oral pathogenic and commensal microorganisms.

Neonates are exposed to microbes in utero and at birth, thereby establishing their microbiota (healthy microbial colonisers). Previously, we reported significant differences in the neonatal oral microbiota of breast-fed and formula-fed babies after first discovering a primal metabolic mechanism that occurs when breastmilk (containing the enzyme xanthine oxidase) and neonatal saliva (containing highly elevated concentrations of the substrates for xanthine oxidase: xanthine and hypoxanthine). The interaction of neonatal saliva and breast milk releases antibacterial compounds including hydrogen peroxide, and regulates the growth of bacteria. Using a novel in vitro experimental approach, the current study compared the effects of this unique metabolic pathway on a range of bacterial species and determined the period of time that microbial growth was affected. We demonstrated that microbial growth was inhibited predominately, immediately and for up to 24 hr following breastmilk and saliva mixing; however, some microorganisms were able to recover and continue to grow following exposure to these micromolar amounts of hydrogen peroxide. Interestingly, growth inhibition was independent of whether the organisms possessed a catalase enzyme. This study further confirms that this is one mechanism that contributes to the significant differences in the neonatal oral microbiota of breast-fed and formula-fed babies.

Concurrent infection of Bluetongue and Peste-des-petits-ruminants virus in small ruminants in Haryana State of India.

Bluetongue (BT) and peste-des-petits-ruminants (PPR) are major transboundary diseases of small ruminant, which are endemic in India. Testing of bluetongue virus (BTV) and peste-des-petits-ruminants virus (PPRV) from recent outbreaks (2015-2016) in different regions of Haryana State of India revealed that 27.5% of the samples showed the presence of dual infection of BTV and PPRV. Analysis of Seg-2 of BTV (the serotype-determining protein) showed the presence of BTV-12w in several isolates. However, analysis of N gene fragment amplicons showed that viruses belong to lineage IV were most closely related to a pathogenic strain of PPRV from Delhi. This is the first report of co-circulation of PPRV lineage IV and bluetongue virus serotype 12 in the state.

Effect of reflux-induced inflammation on transient receptor potential vanilloid one (TRPV1) expression in primary sensory neurons innervating the oesophagus of rats.

A possible mechanism of oesophageal hypersensitivity is the acid-induced activation of transient receptor potential vanilloid receptor 1 (TRPV1) in the primary sensory neurons. We investigated TRPV1 expression and its colocalization with substance P (SP) and isolectin B4 (IB4)-positive cells in the thoracic dorsal root ganglia (DRGs) and nodose ganglia (NGs) of rats with reflux-induced oesophagitis (RO). RO was developed by fundus ligation and partial obstruction of the pylorus of Sprague-Dawley rats. Four groups of rats were used; fundus ligated acute (RO 48 h), chronic 7 days (RO 7D), RO 7D + omeprazole (7D + Omz, 40 mg kg(-1), i.p.) and sham-operated controls. Immunohistochemical analysis of TRPV1, SP and IB4 expression were carried out in spinal cord (SC), DRGs and NGs. RO rats exhibited significant inflammation and increase in TRPV1-ir and SP-ir expressions in the SC, DRGs and NGs. The maximum colocalization of TRPV1 and SP was observed in RO 7D rats, but Omz prevented inflammation and over expression of TRPV1 and SP. TRPV1-ir significantly increased in IB4-positive cells in DRGs and SC, but not in the NGs. Results document that acid-induced oesophagitis increases TRPV1 expression in both SP- and IB4-positive sensory neurons. The over expression of TRPV1 may contribute to oesophageal hypersensitivity observed in gastro-oesophageal reflux disease (GORD).