Is it necessary to stop glucagon-like peptide-1 receptor agonists prior to endoscopic procedure? A retrospective study.

BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are effective in diabetes and obesity, reducing hyperglycemia by increasing insulin release and delaying gastric emptying. However, they can cause gastroparesis, raising concerns about aspiration during procedures. Recent guidelines advise discontinuing GLP-1 RA before surgery to reduce the risk of pulmonary aspiration. AIM: To evaluate the effect of GLP-1 RAs on gastric residual contents during endoscopic procedures. METHODS: A retrospective chart review at BronxCare Health System, New York, from January 2019 to October 2023, assessed gastric residue and aspiration in GLP-1 RA patients undergoing endoscopic procedures. Two groups were compared based on dietary status before the procedure. Data included demographics, symptoms of gastroparesis, opiate use, hemoglobin A1c, GLP-1 agonist indication, endoscopic details, and aspiration occurrence. IBM SPSS was used for analysis, calculating means, standard deviations, and applying Pearson's chi-square and t-tests for associations, with P < 0.05 as being significant. RESULTS: During the study, 306 patients were included, with 41.2% on a clear liquid/low residue diet and 58.8% on a regular diet before endoscopy. Most patients (63.1%) were male, with a mean age of 60 ± 12 years. The majority (85.6%) were on GLP-1 RAs for diabetes, and 10.1% reported digestive symptoms before endoscopy. Among those on a clear liquid diet, 1.5% had residual food at endoscopy compared to 10% on a regular diet, which was statistically significant (P = 0.03). Out of 31 patients with digestive symptoms, 13% had residual food, all from the regular diet group (P = 0.130). No complications were reported during or after the procedures. CONCLUSION: The study reflects a significant rise in GLP-1 RA use for diabetes and obesity. A 24-hour liquid diet seems safe for endoscopic procedures without aspiration. Patients with upper gastrointestinal symptoms might have a higher residual food risk, though not statistically significant. Further research is needed to assess risks based on diabetes duration, gastroparesis, and GLP-1 RA dosing, aiming to minimize interruptions in therapy during procedures.

Survival among patients with lung cancer managed at a tertiary care center in North India.

Though there has been advancement in the management of lung cancer, it is not well utilized due to its limited availability and high cost. This is a prospective observational study done at a tertiary care center from January 2014 to December 2022, involving patients with primary lung cancer. After tumor-node-metastasis staging and molecular testing, the patients received chemotherapy, radiotherapy, surgery, targeted therapy, and immunotherapy in various combinations as per the prevailing National Comprehensive Cancer Network Guidelines. 92 patients were enrolled in the study, with the mean age being 58.94±10.33 and 72 (78.26%) being males. 69 (75%) patients were either current or former smokers. 78 (84.78%) patients had an Eastern Cooperative Oncology Group (ECOG) score of 0-2 while the remaining had an ECOG of 3-4. 80 (86.95%) patients had non-small cell lung cancer (NSCLC) [44 (47.83%) adenocarcinoma, 25 (27.17%) squamous cell carcinoma, and 11 (11.95%) NSCLC: not otherwise specified], while 12 (13.04%) patients had small cell lung cancer. One (1.08%) patient each presented in stage I and stage II, 31 (33.69%) patients presented in stage III, and 59 (64.13%) patients presented in stage IV. 44 patients with adenocarcinoma were subjected to mutational analysis, and an epidermal growth factor receptor mutation was found in 13 (29.5%) patients. None of the patients had ALK mutation, ROS-1 rearrangement, or BRAF mutation. PD-L1 expression was evaluated in 9 patients with NSCLC, and it was found in 6 (66.66%) patients. The overall mean survival was 12.7 months. The mean survival for patients with stages I, II, III, and IV was 70, 96, 8.1, and 12.7 months, respectively. Survival in stage IV was better than in stage III, as the eligible patients received targeted therapy and immunotherapy. Targeted therapy and immunotherapy have improved survival. Molecular analysis should be done whenever indicated, and eligible patients must be administered targeted therapy and immunotherapy.

Novel and recurrent variants in PAX6 in four patients with ocular phenotypes from Southeast Asia.

Aniridia is an autosomal dominant condition characterized by the complete or partial absence of the iris, often with additional presentations such as foveal hypoplasia, nystagmus, cataract, glaucoma and other ocular abnormalities. Most cases are caused by heterozygous mutations in the paired box 6 gene (PAX6), which codes for a transcription factor that regulates eye development. Four patients from our hospital who presented with ocular phenotypes were recruited for research sequencing with informed consent. Sanger sequencing of PAX6 coding exons or exome sequencing was performed on genomic DNA from venous blood samples. Variants in PAX6 were identified in the four patients. Two variants are recurrent single-nucleotide substitutions - one is a substitution found in a patient with bilateral aniridia, whereas the other is a splice variant in a patient with nystagmus and neuroblastoma. The other two variants are novel and found in two patients with isolated aniridia. Both are small duplications that are predicted to lead to premature termination. For the recurrent variants, the comparison of phenotypes for patients with identical variants would shed light on the mechanisms of pathogenesis, and the discovery of two novel variants expands the spectrum of PAX6 mutations.

Evaluation of the Viability of Auditory Steady State Response Testing for Detection of Pseudohypacusis in Serving Personnel of the Indian Armed Forces.

The most popular objective physiologic test for detecting hearing loss that is in use today is the ABR, however it is not frequency specific. The frequency specific tool available for evaluation of hearing is ASSR. The study is aimed to assess the ability of ASSR to estimate hearing thresholds and identify the ideal modulation frequency in hearing impaired personnel. All subjects and controls were subjected to PTA to determine presence/absence of hearing loss, and the nature and configuration of the hearing loss if any. The subjects were then subjected to ASSR testing to objectively ascertain hearing thresholds. The PTA thresholds obtained and the hearing thresholds obtained by ASSR were correlated in this study. The study was carried out in 100 subjects under the age of 50 years (50 with normal hearing & 50 with impaired hearing by PTA) after obtaining informed consent. Moderate correlation was found between PTA and ASSR thresholds only in certain frequencies while in other frequencies the correlation though present, was low. This study concluded that ASSR system could be used to estimate hearing thresholds only approximately as no significant linear correlations were found between PTA thresholds and ASSR at the tested frequencies.

Acute myocarditis masquerading as anterior wall myocardial infarction: A case report.

Introduction: Myocarditis is the inflammation of the myocardium. The clinical presentation of myocarditis ranges from asymptomatic state to acute heart failure which may mimic acute coronary events. Because of the similar presentation of chest pain, elevated cardiac enzymes, and electrocardiographic (ECG) changes, acute myocarditis may rarely masquerade as acute myocardial infarction (AMI). High suspicion is often necessary for treating such patients, keeping in mind the different treatment protocols required for managing each pathology. Methods: SCARE 2020 Guidelines. Case report: We report a case of a young female presenting with sudden onset chest pain with ECG changes suggestive of acute anterior wall myocardial infarction (AWMI). Further investigations ruled out AWMI, and she was diagnosed with acute myocarditis. She was treated for myocarditis and showed a prompt recovery. Discussion: Acute myocarditis may present clinically similarly to ACS; hence a high level of suspicion is required to differentiate the two entities. The absence of significant cardiovascular risk factors for atherosclerotic coronary artery disease, absence of RWMA, and normal coronary angiogram are further suggestive of myocarditis.

Vaginal natural orifice transvaginal endoscopic surgery (vNOTES) surgical staging for endometrial carcinoma: The feasibility of an innovative approach.

OBJECTIVE: This study aims to describe the feasibility of treating early-stage endometrial cancer with hysterectomy, bilateral salpingo-oophorectomy, sentinel lymph node biopsy, and bilateral pelvic lymphadenectomy by vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES). MATERIALS AND METHODS: A longitudinal study of prospectively registered patients was conducted at an academic tertiary care center. 15 patients who underwent vNOTES surgical staging of early endometrial carcinoma between January 2014 and December 2020 were included in the study. RESULTS: 15 patients between 20 and 80yrs of age with histologically proven Stage1 Gr1-2 endometrial cancer underwent vNOTES surgical staging. The mean age of the study population was 52.8 years (Standard Deviation [SD] 6.8) and the mean BMI was 27.8 kg/m2 (SD 6.4). The average operative time was 231.4 min (SD 41.0) with the mean estimated blood loss of 122.0 mL (SD 104.4). A total of 12 (80%) patients underwent SNL biopsy with ICG guided system, whereas 3 (20%) had pelvic lymph node dissection. There was one case with the surgical complication of bladder injury requiring conversion to conventional laparoscopy. CONCLUSION: With this study, we studied the feasibility of vNOTES surgery for early-stage endometrial cancer with minimal complications and the best long-term surgical outcome. The surgeries were performed by a single skilled endoscopist surgeon with previous experience with vNOTES surgery for adnexal tumors and hysterectomy. Our results showed the practicality of vNOTES in staging surgery for early-stage endometrial cancer. However, application to a larger cohort is required for more extensive surgical outcome studies.

Paediatric Cochlear Implantation Outcomes: Parental Expectations and Experiences.

To study parental pre-implant expectations and post-implant experiences of their children's cochlear implant outcomes. Parents of 27 children with cochlear implant participated in the survey. Study investigated and compared the pre-implant expectations and experiences of post-implant outcomes using ICF based questionnaire on items related to domains listening, communication, learning and applying knowledge, interpersonal interactions and relationships and environmental factors. Parental expectations of their children's cochlear implant outcomes were high and largely been met. Benefits with cochlear implant surpassed the expectations in the domains of listening and environmental factors. Positive high correlation was observed between all domains related to expectations. All domains related to experiences of CI outcomes except listening showed positive and significant correlation with each other. No correlation was observed between child variables; current age, age at implantation and implant age and any of the domains. With regards to expectations, fathers held significantly high expectations when compared to mothers. Parents demonstrate high pre-implant expectations and positive experiences post cochlear implantation across range of outcomes.

Treating Deep Endometriosis in Infertile Patients before Assisted Reproductive Technology.

Deep endometriosis (DE) causes infertility and pelvic pain. Surgical management of DE has become a topic of increasing interest in gynecological surgery. In women desirous of pregnancy, optimal management such as surgery versus first-line assisted reproductive technology (ART) for patients with severe endometriosis is strongly debated. Current guidelines and literature including retrospective and prospective studies in English available on DE surgery, infertility, and pregnancy outcomes following surgery were searched in Cochrane Library with DE, DIE, Infertility, "DE surgery and pregnancy outcomes," and "Deep infiltrating endometriosis and assisted reproduction" as keywords. The purpose was to find evidence to answer the following clinical questions: How does DE affect fertility and pregnancy? What are the possible benefits of primary surgery for DIE before in vitro fertilization (IVF)? Several studies have recently concluded that surgical removal of DE nodules might actually have a favorable impact on IVF outcomes. This is in contradiction to European Society of Human Reproduction and Embryology statement which stated that there was no evidence supporting surgical management of DE prior to ART to improve pregnancy rate; several studies have suggested that the surgical removal of DE nodules might actually have a favorable impact on IVF outcomes. Treatment of DE affecting the rectovaginal septum or bowel requires complex surgery with considerable risk of complications. This review article tries to analyze the rationale of surgical treatment of DE before ART. A balance must be struck between exposing the patient to surgical risk and improvement in pain and fertility potential. Decisions should be tailored according to the individual needs of each woman and most importantly on the ability of the surgeons.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery Myomectomy Followed by Hysterectomy.

Transvaginal surgery is the most minimally invasive surgery for a gynecologic procedure. A 67-year-old woman who had four children with vaginal deliveries and one abortion, with no underlying disease and a body mass index of 22.4 kg/m2, came to the hospital due to menorrhagia. Her diagnosis was myoma uteri from an asymptomatic palpated mass at the lower abdomen. The ultrasonography showed a 9 cm × 5.9 cm myoma mass at the anterior wall of the uterus. After counseling, the transvaginal natural orifice transluminal endoscopic surgery (NOTES) operation was conducted on May 2018. The process was a transvaginal NOTES hysterectomy following a transvaginal NOTES-assisted myomectomy. The uterine weight was 376 g. In this case, the surgeons could not enter into the pelvic cavity completely because the myoma mass was attached to the bladder which led to the surgeons safely performing the transvaginal NOTES myomectomy before the hysterectomy.

Current strategies for quantification of estrogens in clinical research.

Estrogens and their bioactive metabolites play key roles in regulating diverse processes in health and disease. In particular, estrogens and estrogenic metabolites have shown both protective and non-protective effects on disease pathobiology, implicating the importance of this steroid pathway in disease diagnostics and monitoring. All estrogens circulate in a wide range of concentrations, which in some patient cohorts can be extremely low. However, elevated levels of estradiol are reported in disease. For example, in pulmonary arterial hypertension (PAH) elevated levels have been reported in men and postmenopausal women. Conventional immunoassay techniques have come under scrutiny, with their selectivity, accuracy and precision coming into question. Analytical methodologies such as gas and liquid chromatography coupled to single and tandem mass spectrometric approaches (GC-MS, GC-MS/MS, LC-MS and LC-MS/MS) have been developed to quantify endogenous estrogens and in some cases their bioactive metabolites in biological fluids such as urine, serum, plasma and saliva. Liquid-liquid or solid-phase extraction approaches are favoured with derivatization remaining a necessity for detection in lower volumes of sample. The limits of quantitation of individual assays vary but are commonly in the range of 0.5-5 pg/mL for estrone and estradiol, with limits for their bioactive metabolites being higher. This review provides an overview of current approaches for measurement of unconjugated estrogens in biological matrices by MS, highlighting the advances in this field and the challenges remaining for routine use in the clinical and research environment.

Derivatization enhances analysis of estrogens and their bioactive metabolites in human plasma by liquid chromatography tandem mass spectrometry.

Estrogens regulate many diverse biological processes in health and disease. They circulate at a wide range of concentrations in females generating several active metabolites (hydroxy and methoxyestrogens). The metabolites are assumed to be present in much lower levels and are thought to contribute to diseases such as pulmonary arterial hypertension (PAH). Estrogen metabolites are challenging to quantify in plasma and currently available immunoassays are non-specific. Here we have developed and validated a novel assay to simultaneously quantify parent estrogens and their metabolites by mass spectrometry (MS). Estrogens were extracted from human plasma using solid phase extraction and derivatized using 1-(5-fluoro-2, 4-dinitrophenyl)-4-methylpiperazine (PPZ) before quaternization by methylation ("MPPZ"). MPPZ derivatives were separated and quantified by liquid chromatography tandem MS (LC-MS/MS) in positive electrospray ionization mode, using a QTrap 6500 + coupled to a Shimadzu Nexera X2. Separation was achieved using an ACE Excel 2 C18-PFP column (2 µm, 2.1 mm × 150 mm). The limits of quantification (LOQ) were 0.43-2.17 pg on column with a linear range from 2 or 10 - 2000 pg mL-1. Intra and inter-day precision and accuracy were acceptable (<20% at LOQ and <15% above). These derivatives demonstrated minimal degradation upon short-term storage at 15 °C (<20%) and longer term at -20 °C (<20%). Using this approach, estrone (E1) and estradiol (E2) were detected in plasma (0.5 mL) from healthy women and those with PAH but downstream metabolites 16-hydroxy-E1, 16-hydroxy-E2, 2-methoxy-E1 and 4-methoxy-E1 were only detected in plasma from diseased patients. These findings will next be tested robustly in large patient cohorts. This novel LC-MS/MS analysis of estrogens and their bioactive metabolites, using MPPZ derivatization, opens doors for the simultaneous analysis of a panel of estrogens in human plasma, across the endogenous range of concentrations encountered in health and disease.

Affordable and rapid HPTLC method for the simultaneous analysis of artemisinin and its metabolite artemisinic acid in Artemisia annua L.

Artemisinin (AN) and artemisinic acid (AA), valuable phyto-pharmaceutical molecules, are well known anti-malarials, but their activities against diseases like cancer, schistosomiasis, HIV, hepatitis-B and leishmaniasis are also being reported. For the simultaneous estimation of AN and AA in the callus and leaf extracts of A. annua L. plants, we embarked upon a simple, rapid, selective, reliable and fairly economical high performance thin layer chromatography (HPTLC) method. Experimental conditions such as band size, chamber saturation time, migration of solvent front and slit width were critically studied and the optimum conditions were selected. The separations were achieved using toluene-ethyl acetate, 9:1 (v/v) as mobile phase on pre-coated silica gel plates, G 60F254 . Good resolution was achieved with Rf values of 0.35 ± 0.02 and 0.26 ± 0.02 at 536 nm for AN and 626 nm for AA, respectively, in absorption-reflectance mode. The method displayed a linear relationship with r(2) value 0.992 and 0.994 for AN and AA, respectively, in the concentration range of 300-1500 ng for AN and 200-1000 ng for AA. The method was validated for specificity by obtaining in-situ UV overlay spectra and sensitivity by estimating limit of detection (30 ng for AN and 15 ng for AA) and limit of quantitation (80 ng for AN and 45 ng for AA) values. The accuracy was checked by the recovery studies conducted at three different levels with the known concentrations and the average percentage recovery was 101.99% for AN and 103.84% for AA. The precision was analyzed by interday and intraday precision and was 1.09 and 1.00% RSD for AN and 1.22 and 6.05% RSD for AA. The analysis of statistical data substantiates that this HPTLC method can be used for the simultaneous estimation of AN and AA in biological samples.

INTERRUPTED VERSUS CONTINUOUS SUTURES FOR REPAIR OF EPISIOTOMY OR 2N DEGREE PERINEAL TEARS.

BACKGROUND: Performing an episiotomy is generally reserved for complicated childbirths, in cases of foetal distress, or when tearing of tissues with serious consequences are foreseen. In addition to the extent of the trauma, the surgical skill, repair after childbirth can have an important effect on the magnitude and degree of morbidity experienced by women after repair. The best technique for this repair would be that which produces less pain in the short and long term. The study was done with an objective to compare the frequency and severity of pain (slight/severe) by using interrupted and continuous methods for repair of episiotomy or second degree perineal tears. METHODS: It is a randomized control trial. This study was carried out in a Gynaecology and Obstetrics department of Benazir Bhutto Hospital Rawalpindi which is a tertiary care hospital. The duration of study was six months. One hundred & thirty-eight primigravidas (69 in each group) were included in the study. RESULTS: Majority of the patients in both groups belonged to 20-25 years age group, i.e., 48.53% (n=33) in group-A and 50% (n=34) in group-B, mean and SD, was 27.69±3.21 in group-A and 28.16±3.89 in group-B, gestation age of the patients in group-A 77.94% (n=53) and 83.82% (n=57) in group-B between 37-40 weeks of gestation. Complication of pain and its severity in both groups at 24 hours and 10th day were compared which showed no significant difference at any severity (i.e., no pain, mild moderate/severe). CONCLUSION: There is no significant difference in frequency and severity of pain (slight/severe) in using interrupted and continuous methods for repair of second degree perineal tears or episiotomy

Comparison of CT scan and colour flow Doppler ultrasound in detecting venous tumour thrombous in renal cell carcinoma.

BACKGROUND: Renal cell carcinoma has marked tendency to spread into renal vein, inferior vena cava and right side of heart. Extension of tumour thrombus into these veins will alter the surgical approach. We have compared the CT scan with Colour flow Doppler ultrasound in detecting venous tumour thrombus in renal vein and inferior vena cava. METHODS: This cross-sectional study included 30 adult patients presenting with renal tumour. Patients of either gender were included in the study. Non probability convenience sampling was used. All patients underwent colour flow Doppler ultrasound and CT scan with contrast to asses the renal vein and inferior vena cava. The results were confirmed by intra operative findings and histopathology. The data was analyzed using SPSS version 12. RESULTS: Out of 30 patients, 20 (66%) were males and 10 (34%) female. The tumour was predominantly on the right side (60%), as was renal venous tumour thrombus (44%). Inferior vena cava was involved in 4 cases predominantly due to right sided tumours. The sensitivity of Doppler ultrasound in detecting renal venous tumour thrombus (88% on right and 100% on left side) was higher than CT scan (63% on right and 60% on left side). Doppler ultrasound was also superior to CT scan in detecting vena caval thrombus. CONCLUSION: The overall sensitivity of Doppler sonography was higher than CT scan in detecting tumour extension into renal veins and inferior vena cava. Therefore, it can be used as a complementary tool in equivocal cases.

Female sexual dysfunction: classification, pathophysiology, and management.

Female sexual dysfunction is a prevalent problem in the general community; however, it has not been studied as extensively as male sexual dysfunction. Female sexual dysfunction is a common complication after most pelvic surgeries. With the introduction of screening programs, most pelvic malignancies are detected at earlier stages and in younger patients. Sexual dysfunction is a major quality-of-life issue in these young women. Hysterectomy (simple or radical) is the most common type of pelvic surgery in women and is one of the most important causes of female sexual dysfunction. Additionally, female sexual dysfunction is an important issue after urologic (radical cystectomy) and colorectal surgeries (simple and radical proctocolectomy). Sexual dysfunction is a common problem among postmenopausal women. Modifications in the surgical technique (nerve sparing) are rapidly evolving in the field of urology and colorectal surgery, which will be soon followed by modifications in the field of gynecologic surgery. In this article we summarize the pathophysiology and classification of female sexual dysfunction, with special emphasis on the relationship between female sexual dysfunction and pelvic surgeries.

Novel cancer therapies: targeting the molecules.

Translational research is providing the means to develop a growing arsenal of targeted oncologic therapies (see Table 2, page 31). In practice, some of these drugs have completely changed the treatment pathway for common cancers. Many patients can be treated with greater efficacy and fewer side effects than traditional therapies allowed. Some patients with poor performance status have been able to undergo treatment when they would otherwise not have qualified for it. Some agents have not been shown to improve overall survival, but they do offer the possibility for improvement in quality of life. Although not miracle cures, these current targeted therapies offer proof of principle for scientists and hope for millions of patients.