Pain in chronic pancreatitis: What can we do today?

The aim of this study is to illustrate the complexity of pain management in chronic pancreatitis (CP). In this context, pain represents the most common and debilitating symptom, and it deeply affects patient's quality of life. Multiple rating scales (unidimensional, bidimensional and multidimensional) have been proposed to quantify CP pain. However, it represents the result of complex mechanisms, involving genetic, neuropathic and neurogenic factors. Considering all these aspects, the treatment should be discussed in a multidisciplinary setting and it should be approached in a stepwise manner. First, a lifestyle change is recommended and nonsteroidal anti-inflammatory drugs represent the gold standard among medical treatments for CP patients. The second step, after medical approach, is endoscopic therapy, especially for complicated CP. In case of failure, tailored surgery represents the third step and decompressive or resection procedures can be chosen. In conclusion, CP pain's management is challenging considering all these complex aspects and the lack of international protocols.

Novel time-saving OGTT sparing HbA1c-HOMA2 based algorithm for the diagnosis of cystic fibrosis-related diabetes.

AIMS: The diagnosis of cystic fibrosis-related diabetes (CFRD) faces several challenges. We propose a novel screening algorithm to alleviate the burden of cystic fibrosis (CF). METHODS: Through a retrospective cross-sectional single-centre study, HbA1c and HOMA2 indices were assessed in multiple models as alternative diagnostic tools from OGTT data. We sought to establish specific thresholds for CFRD screening with oral glucose tolerance test (OGTT) as gold standard. We evaluated various straightforward or sequential approaches, in terms of diagnostic accuracy while also quantify the potential reduction in OGTTs through these different methods. RESULTS: HOMA indices were recovered in 72 patients. We devised a composite index that combines HbA1c and HOMA-B: Diabetes Predicting Index in cystic fibrosis (DIPIc) = (HbA1c(%) × 3.455) - (HOMA-B(%) ×  0.020) - 19.294. This index yields the highest screening accuracy according to receiver-operating characteristics curves. Using a stepwise algorithm that incorporates DIPIc decreases the requirement for annual OGTTs. A CFRD exclusion cutoff less than -1.7445 (sensitivity 98 %), in conjunction with a CFRD diagnostic threshold greater than 0.4543 (specificity 98 %) allows for 71 % OGTT sparing. CONCLUSION: The composite index DIPIc is a suitable, less invasive screening method for CFRD, which enables to avoid many OGTTs.

Application of Boston Compensation Rules in the Development of a Stepwise Approach for Novel Diagnostic Arterial Blood Gas Interpretation Method.

Background: Arterial blood gas (ABG) interpretation plays an indispensable role in health care. The total changes in hydrogen ion concentration or actual pH are due to both the changes in respiratory and non-respiratory (metabolic) components affecting the hydrogen ion concentration or pH in the acid-base homeostasis. Using this concept, an innovative ABG interpretation method was developed and published by the current author. The aim of this study is to apply the compensation rules and to develop a stepwise approach in this novel method to interpret various acid-base disorders. Methods: The total change in pH (ΔpH), non-respiratory hydrogen ion concentration (NRH+), changes in non-respiratory pH (ΔNRpH), and respiratory change in pH (ΔRpH) were calculated for 232 ABG samples. The expected pCO2 (Exp pCO2) or expected bicarbonate (Exp HCO3-) values were calculated using the compensation rules and compared with their actual given values. Results: Few acid-base disorder cases were shown as examples comparing the physiological, standard base excess (Std BE) and parameters such as ΔpH, ΔRpH, and ΔNRpH values of novel ABG interpretation method which change in different acid-base disorders. Conclusion: The stepwise approach in this novel method appears to be much user-friendly providing interpretation of various acid-base disorders easily and quickly. Clinical significance: This innovative method may help to overcome the challenging task of ABG interpretation. How to cite this article: Samuel R. Application of Boston Compensation Rules in the Development of a Stepwise Approach for Novel Diagnostic Arterial Blood Gas Interpretation Method. Indian J Crit Care Med 2023;27(10):717-723.

Workup of difficult-to-treat asthma: implications from treatable traits.

Traditional stepwise approach usually adjusts the treatment regimen based on changes in asthma symptoms and severity to achieve good asthma control. However, due to the generalized heterogeneity and complexity of asthma, its therapeutic efficacy in difficult-to-treat asthma is limited. Recently, a precision medicine approach based on the identification and intervention of treatable traits of chronic airway disease has been proposed and appears to be of greater benefit to asthmatics. We reported a 71-year-old male with uncontrolled asthma and multiple exacerbations over the past year. He complained of persistent dyspnea despite high-dose of inhaled corticosteroids plus other controllers. Does this patient have some potential treatable traits contributing to difficult-to-treat asthma? Through a multidimensional assessment of three domains including pulmonary, extrapulmonary, and behavioral/risk factors, 15 treatable traits were identified in the patient, mainly including airflow limitation, eosinophilic airway inflammation, small airway dysfunction, exacerbation prone, dilated cardiomyopathy, diabetes mellitus, inhaler device polypharmacy, smoking, and the absence of an asthma action plan. After targeted treatment for these treatable traits, the patient experienced significant improvement in dyspnea and he could maintain good asthma control with low-dose inhaled corticosteroids and long-acting ß2-agonist. This study shows that, in response to the limitation of a stepwise approach to therapy, treatable traits is a new strategy where patients are individually assessed for a specified set of treatable problems, and an individualized treatment program is developed and implemented based on this multidimensional assessment, especially for difficult-to-treat asthma.

How alcohol and/or tobacco use and raised glycemia are associated with oral hygiene practices among Burkinabè adults: Evidence from the first national non-communicable disease risk factors survey.

Socio-demographic correlates with oral hygiene practices are commonly investigated. The present study aimed to determine whether alcohol and/or tobacco use and hyperglycemia were associated with oral hygiene practices among Burkinabè adults. This descriptive, cross-sectional study included 4550 adults selected through multistage cluster sampling performed during the first WHO STEPS survey conducted in 2013 in Burkina Faso. The practices we considered were the frequencies of tooth cleaning, the fluoridated toothpaste use and the dentist visit within the past-six months. We collected data on self-reported alcohol and tobacco use and measured fasting blood glucose (FBG). About 82.8% of respondent reported they cleaned their teeth at least once a day, 31.5% cleaned them at least twice a day, 25.4% used fluoridated toothpaste, 2.2% had visited a dentist in the past six months, 38.8% used either alcohol or tobacco and 8.4% had raised FBG. After adjusting for socio-demographic factors, alcohol and/or tobacco use was an unfavorable factor for tooth cleaning at least once a day [aOR = 0.7 (0.6-0.8) p < 0.001], or at least twice a day [aOR = 0.6 (0.5-0.7) p < 0.001]. Moreover, raised FBG was negatively associated with cleaning tooth at least twice a day [aOR = 0.7 (0.5-0.9) p < 0.01] or the use of fluoridated toothpaste [aOR = 0.7 (0.6-0.9) p < 0.05]. Oral health education in addition to cardiovascular risk factor reduction should be efficiently integrated in the behavioral lifestyle interventions' strategies for the non-communicable diseases' prevention.

Epidemiology of Young Stroke in the Ludhiana Population-Based Stroke Registry.

Objective: The objective of the study was to determine incidence, risk factors, and short-term outcomes of young stroke in Ludhiana city, Northwest India. Methods: Data were collected on first-ever stroke in patients of age ≥18 years, from hospitals, diagnostic imaging centers, general practitioners, and municipal corporation during March 2011-March 2013 in Ludhiana city, using the World Health Organization Stepwise Approach to Surveillance (WHO STEPS). Outcome was documented using the modified Rankin Scale at 28 days. Results: Of 2948 patients, 700 (24%) were in the age group 18-49 years. Annual incidence in this age group was 46/100,000 person-years (95% confidence interval [CI], 41-51/100,000). Hypertension (84%), diabetes mellitus (48%), and atrial fibrillation (AF) (12%) were found more common in >49 years age group, as compared with 18-49 years age group. Drug abuse (8.7% vs. 6% in age >49 years; P = 0.04) and tobacco intake (8.7% vs. 5.6% in age >49 years; P = 0.02) was more common in young people, that is, 18-49 years age group in comparison to older patients, >49 years age group. Recovery was better in younger subjects (60% vs. 46% in age >49 years P < 0.001). In a multivariable analysis, younger people were more often literate (odds ratio [OR] 2.52; 95% CI, 1.68-3.77; P < 0.001), employed (OR 3.92; 95% CI, 2.20-5.21; P < 0.001), and 374 (60%) had good clinical outcome, modified Rankin Scale <2 at 28 days follow-up as compared with 938 (46%) older patients (OR 1.52; 95% CI, 1.15-2.00; P = 0.003). Conclusion: Hypertension, diabetes mellitus, drug addiction, and tobacco intake were significantly associated with young stroke. Outcome was also better in younger people.

Effective treatment of acid mine drainage using a combination of MgO-nanoparticles and a series of constructed wetlands planted with Vetiveria zizanioides: A hybrid and stepwise approach.

In this novel study, acid mine drainage (AMD) was treated using a hybrid approach comprising a nano-and-biotic system synergistically integrated in a step-wise and modular fashion. Specifically, the treatment chains were made up of different stages, which comprise, neutralization using activated magnesite or MgO-nanoparticles (NPs) (Stage 1) and polishing the product water using a series of wetlands (Stage 2) in a step-wise connection. In stage One (1), real AMD was treated with MgO-NPs at a ratio of 1:100 (1 g/100 mL - w/v ratio), 500 rpm of mixing speed, and One (1) hour of hydraulic retention time (HRT) whilst in stage 2, the final water was fed into constructed wetlands, i.e. Three (3) interconnected wetland with different flow modalities [(I) subsurface vertical flow (SSVF-CW), (II) free water surface flow (FWS-CW), and (III) subsurface horizontal flow (SSHF-CW)], for further purification and polishing to the desired product. In this stage, i.e. stage 2, the product water and substrate were collected daily at the outlet and bottom of each wetland. After the treatment process, the pH of the product water was observed to have increased from 2.6 to 10.4. Significant removal of inorganic contaminants was also observed and the following removal sequence was registered, Fe (99.8%) ≥ Al (99.5%) ≥ Mn (99.24%) ≥ Zn (98.36%) ≥ Cu (97.38%) ≥ Ni (97.7%) ≥ SO42─ (80.59%). Reduction in electrical conductivity (EC) was also observed (86%). Specifically, the nano-part removed the metals and sulphate partially whereas the bio-part effectively removed SO42─ and EC levels, thus denoting stellar combination and complementary performance for the hybrid system in integrated fashion. The state-of-the-art analytical instruments were used to underpin and succinct the fate of chemical species in raw and product MgO-NPs, substrates, and the grass. Finally, the product water conformed to the prescribed standards for effluent discharge hence proving that the synergy of neutralization and bio-remediation, i.e. nano-and-biotic system, could potentially yield the desired results in mine water management and afield. This will go a long way in curtailing ecological footprints associated with mining activities thus fostering the concept of sustainable development.

Constipation and fecal incontinence in children with cerebral palsy. Overview of literature and flowchart for a stepwise approach.

BACKGROUND AND STUDY AIMS: Constipation and fecal incontinence are common problems in neurologically impaired children. This paper aims to give an overview on bowel problems in cerebral palsy children and to suggest a stepwise treatment approach. A pubmed search was performed looking at studies during the past 20 years investigating bowel problems in neurologically disabled children. RESULTS: The search revealed 15 articles. Prevalence and presentation was the subject of 8 papers, confirming the importance of the problem in these children. The other papers studied the results of different treatment modalities. No significant differences between treatment modalities could be demonstrated due to small studied cohorts. Therefore, no specific treatment strategy is currently available. An experienced based stepwise approach is proposed starting with normalization of fiber intake. The evaluation of the colon transit time could help in deciding whether desimpaction and eventually laxatives including both osmotic (lactulose, macrogol) as well as stimulant laxatives might be indicated. Or, in case of fast transit loperamide or psyllium can be tried. Surgery should be a last resort option. CONCLUSION: Studies investigating constipation and continence in neurologically impaired children are scarce, making it difficult to choose for the optimal treatment. A stepwise treatment approach is proposed, measuring the colon transit time to guide treatment choices.

An Evidence-Based Stepwise Surgical Approach to Cervical Spondylotic Myelopathy: A Narrative Review of the Current Literature.

OBJECTIVE: Cervical spondylotic myelopathy (CSM) is the most common progressive degenerative disease of the spine in the geriatric population. The aim of the current review is to provide an evidence-based stepwise surgical approach to CSM according to the recent literature. METHODS: We searched for evidence regarding the surgical approach to CSM in medical databases with articles dated from 1985 to 2016. RESULTS: In patients with effective cervical lordosis (fewer than 3 levels of ventral disease), anterior cervical discectomy and fusion (ACDF) or arthroplasty is preferred. Patients with more than 3 levels of compression are generally treated by laminoplasty, especially with preserved lordotic curvature. In patients with straightened spine who have less than 3 involved levels, ACDF with a plate is recommended, whereas patients with more than 3 involved levels with instability should undergo posterior decompression and fusion. In young patients who have a stable cervical spine, laminoplasty is recommended and in old patients with ankylosed spine, only laminectomy should be performed. Patients with mild cervical kyphosis (kyphotic angle ≤10°) should be managed in the same way as patients with straightened spine. However, in severe kyphosis, cervical traction is recommended. If the kyphosis is reducible, further posterior decompression and fusion is adequate. In patients with irreducible kyphosis, if the number of involved levels is less than 2, ACDF is adequate, but if it is more than 2 levels, anterior cervical corpectomy and fusion should be performed using cervical magnetic resonance imaging for evaluation of the patency of the subarachnoid space (SAS). With patent SAS, only posterior fusion is adequate, whereas in closed SAS, posterior decompression with posterior fusion is required. These approaches are based on the most recent evidence. CONCLUSIONS: This article provides a stepwise evidence-based surgical approach for the management and treatment of patients with CSM.

Diagnosis and Management of Drooling in Children With Progressive Dystonia: A Case Series of Patients With MEGDEL Syndrome.

Drooling is a common problem in children with progressive dystonia. The authors noted a 58% incidence of drooling in 22/38 children with MEGDEL, a rare neurodegenerative cause of dystonia and report on the clinical course of four patients. Drooling of varying severity and subsequent respiratory problems were treated at the authors' multidisciplinary saliva-control outpatient clinic. One patient improved on antireflux medication, the second after medication with drooling as side effect was changed. Two other patients underwent salivary gland surgery, one of whom significantly improved; the other died shortly after surgery. The heterogeneity of the cases presented shows the need for stepwise and personalized treatment. The authors recommend the following: (1) optimize the treatment of the underlying neurological condition and replace medication that stimulates saliva secretion; (2) treat constipation, scoliosis, and gastroesophageal reflux if there is still a risk of chronic aspiration of saliva; (3) perform more intense/invasive treatment (botulinum toxin, salivary gland surgery).

Five-year follow-up after catheter ablation of persistent atrial fibrillation using the stepwise approach and prognostic factors for success.

BACKGROUND: In the meantime, catheter ablation is widely used for the treatment of persistent atrial fibrillation (AF). There is a paucity of data about long-term outcomes. This study evaluates (1) 5-year single and multiple procedure success and (2) prognostic factors for arrhythmia recurrences after catheter ablation of persistent AF using the stepwise approach aiming at AF termination. METHODS AND RESULTS: A total of 549 patients with persistent AF underwent de novo catheter ablation using the stepwise approach (2007-2009). A total of 493 patients were included (Holter ECGs ≥ every 6 months). Mean follow-up was 59 ± 16 months with 2.1 ± 1.1 procedures per patient. Single and multiple procedure success rates were 20.1% and 55.9%, respectively (80% off antiarrhythmic drug). Antiarrhythmic drug-free multiple procedure success was 46%. Long-term recurrences (n=171) were paroxysmal AF in 48 patients (28%) and persistent AF/atrial tachycardia in 123 patients (72%). Multivariable recurrent event analysis revealed the following factors favoring arrhythmia recurrence: failure to terminate AF during index procedure (hazard ratio [HR], 1.279; 95% confidence interval [CI], 1.093-1.497; P = 0.002), number of procedures (HR, 1.154; 95% CI, 1.051-1.267; P = 0.003), female sex (HR, 1.263; 95% CI, 1.027-1.553; P = 0.027), and the presence of structural heart disease (HR, 1.236; 95% CI, 1.003-1.524; P = 0.047). AF termination was correlated with a higher rate of consecutive procedures because of atrial tachycardia recurrences (P = 0.003; HR, 1.71; 95% CI, 1.20-2.43). CONCLUSIONS: Catheter ablation of persistent AF using the stepwise approach provides limited long-term freedom of arrhythmias often requiring multiple procedures. AF termination, the number of procedures, sex, and the presence of structural heart disease correlate with outcome success. AF termination is associated with consecutive atrial tachycardia procedures.

Descriptive epidemiology of cardiovascular risk factors and diabetes in sub-Saharan Africa.

Reliable data on risk factor levels, exposure history, and population distribution can help inform policies and programs for disease prevention and control. With rare exception however, ideal local data on major risk factors and causes of death and disease burden have been scarce in sub-Saharan Africa (SSA). Basic community surveys in some countries and recent systematic analysis of disease burden attributable to 67 risk factors and risk factor clusters in 21 regions of the world provide an opportunity to examine and relate diabetes and cardiovascular risk factors to mortality and burden in SSA. Rising body mass index, especially in women in Southern Africa; and rising systolic blood pressure in East Africa for both sexes, and in West Africa for women are the major cardiometabolic risk factors. Harmful use of alcohol, especially in Southern SSA, tobacco use, and physical inactivity are also important. Improving vital registration and risk factor surveillance remain major challenges.