Utility of myxedema score as a predictor of mortality in myxedema coma.

OBJECTIVE: Myxedema crisis (MC) is a rare condition. There is a dearth of data regarding the predictors of mortality in MC. Predictive scores for mortality specific to the clinical and biochemical profile of MC are still lacking. DESIGN AND METHODS: All consecutive patients presenting with MC from September 2006 to December 2020 comprised the new cohort. Patients managed between January 1999 and August 2006 comprised the old cohort. Both cohorts were compared for the determination of secular trends. Combined analysis of both the cohorts was done for clinico-demographic profile and predictors of mortality. Myxedema score (MS) and qSOFA (Quick Sequential Organ Failure Assessment) score were evaluated in all the patients. RESULTS: A total of forty-one patients (new cohort; n = 18 and old cohort; n = 23) were enrolled into the study. There was a female predominance (80.5%). Nearly half (51.2%) of the patients were newly diagnosed with hypothyroidism on admission. Overall mortality was 60.9%. On comparative analysis among survivors and non-survivors, female gender (OR 20.4, p value 0.018), need for mechanical ventilation (OR16.4, p value 0.009), in-hospital hypotension (OR 9.1, p value 0.020), and high qSOFA score (OR 7.1, p value 0.023) predicted mortality. MS of > 90 had significantly higher mortality (OR-11.8, p value - 0.026) while MS of > 110 had 100% mortality. There was no change in secular trends over last 20 years. There was no difference in outcome of patients receiving oral or IV levothyroxine. CONCLUSION: Myxedema crisis is associated with high mortality despite improvement in health care services. The current study is first to elucidate the role of the MS in predicting mortality in patients with MC.

A Meta-Analysis on Comparison of Open vs Closed Reduction of Gartland Type 3 Supracondylar Humerus Fractures in Children.

PURPOSE OF THE STUDY Although there are numerous studies on outcomes and comparison of open and closed reduction but there is no clarity on relationship between outcomes and complications with type of surgical intervention done for Type 3 Gartland supracondylar humerus fracture. The aim of this study is to compare the outcomes and complications of closed vs open reduction in Type 3 Gartland supracondylar humerus fractures. MATERIAL AND METHODS Electronic literature searches of Embase, MEDLINE and the Cochrane Library was conducted in February 2022 using the terms "supracondylar", "humerus", "fracture", "Gartland type 3" and synonymous. The data extracted included the study details, demographic data, procedure performed, final functional and cosmetic outcome according to Flynn criteria and complications of included studies. RESULTS Pooled data analysis revealed no significant difference in mean satisfactory outcome rate according to Flynn cosmetic criteria in open group (97%, 95% CI 95.5%-98.5%), as compared to closed group (97.5%, 95% CI 96.3%-98.7%), although a statistically significant difference in mean satisfactory rate according to Flynn functional criteria in open group (93.4%, 95% CI 90.8%- 96.1%) as compared to closed group (98.5%, 95% CI 97.5%-99.4%) was noted. On separate comparison of the two-arm studies, closed reduction favoured better functional outcomes (RR 0.92, 95% CI 0.86-0.99). CONCLUSIONS Closed reduction and percutaneous fixation have better functional outcome than open reduction with K-wire fixation. But there was no significant difference in cosmetic outcomes, overall complication rate and nerve injury with either open or closed reduction. The threshold of converting a closed reduction to an open reduction in supracondylar humerus fractures of children should be high. Key words: supracondylar humerus, open reduction, percutaneous pinning, Flynn criteria.

Unravelling a novel, promising and convenient tool for differential diagnosis of delayed puberty: GnRHa-stimulated inhibin B (GnRH-iB).

BACKGROUND: Etiological diagnosis of delayed puberty is difficult. Despite availability of various basal and stimulation tests differentiation between constitutional delay in puberty and hypogonadotropic hypogonadism is still challenging. OBJECTIVE: To elucidate the role of GnRH agonist-stimulated inhibin B (GnRH-iB) for the differential diagnosis of delayed puberty. STUDY DESIGN: Participants were recruited into "exploratory cohort" (n = 39) and "validation cohort" (n = 16). "Exploratory cohort" included children with spontaneous puberty and patients with hypogonadotropic hypogonadism. "Validation cohort" constituted children who presented with delayed puberty. INTERVENTION AND OUTCOME: GnRHa (Triptorelin) stimulation test along with measurement of inhibin B level at 24 h after GnRHa injection was performed in all the study participants. Cut-offs for GnRH-iB were derived from the "exploratory cohort". These cut-offs were applied to the "validation cohort". Basal LH, basal inhibin B(INH-B), GnRHa-stimulated LH at 4 h (GnRH-LH) and GnRH-iB were evaluated for the prediction of onset of puberty on prospective follow-up. RESULTS: GnRH-iB at a cut-off value of 113.5 pg/ml in boys and 72.6 pg/ml in girls had 100% sensitivity and specificity for the documentation of puberty. In the "validation cohort" basal LH, basal INH-B, GnRH-LH, and GnRH-iB had a diagnostic accuracy of 68.75%, 81.25%, 68.75% and 93.75% respectively, for the prediction of onset of puberty. Basal LH, basal INH-B and GnRH-LH used alone or in combination were inferior to GnRH-iB used alone. CONCLUSION: GnRHa-stimulated inhibin B (GnRH-iB) is a convenient and easily employable test for the differentiation of constitutional delay in puberty from hypogonadotropic hypogonadism. CTRI REGISTRATION NO: CTRI/2019/10/021570.

Ischemic and Bleeding Profile of Patients on Dual Antiplatelet Therapy beyond 1 Year of Index Acute Coronary Syndrome / Percutaneous Intervention.

Dual antiplatelet treatment (DAPT) is the cornerstone of the management and prophylaxis of acute coronary syndrome (ACS). However, the associated risk of bleeding with the usage of DAPT and risk of thrombosis with stoppage of the drug makes it a challenging task to take appropriate decisions regarding the choice and duration of DAPT. The present study is aimed to tackle these challenges and to analyze whether prolonged dual antiplatelet therapy carries more risk of bleeding or a higher risk of thrombosis is present with discontinuation of the same. MATERIAL: In this study, a total of 235 cases of confirmed myocardial infarction, unstable angina, or those who underwent percutaneous intervention were included. After 1 year, the number of patients on DAPT, the type of antiplatelets they were using were observed, their ischemic risk was calculated using DAPT score, and bleeding risk was calculated using PRECISE-DAPT score. Bleeding events were assessed using BARC classification. OBSERVATION: Out of 235 patients, the majority of the patients were males (78.7%). Only 7.2% of the patients had bleeding since the start of the drugs. The majority (5% out of 7.2%) of bleeding episodes were clinically insignificant. 163 (69%) patients were on Dual antiplatelet therapy after 1 year. Out of which 115 were appropriately taking DAPT as per their DAPT score. Patients with high bleeding risk (PRECISE DAPT score ≥25) were 89, out of which 38 (53.2%) patients were taking SAPT, appropriate for their bleeding risk. While 112 (68.7%) were taking prolonged DAPT, appropriate for PRECISE-DAPT risk. CONCLUSION: The majority of patients remained on DAPT following discharge for more than 1 year after ACS. This suggests that treating physicians prioritizes ischemic risk reduction over bleeding risk in patients with ACS, according to the patient's risk profile.

Association of Serum Ferritin Levels with Microalbuminuria, Glycemic Control and Dyslipidemia.

As diabetes is on the rise worldwide, early screening and detection of its complications is crucial. The first clinical sign of renal dysfunction in diabetes is microalbuminuria. Ferritin may have a possible role in the development and prediction of microalbuminuria and other complications of diabetes by 3 possible mechanisms- 1) it is a marker of elevated body iron stores. 2) acts as acute-phase reactant and elevation reflects inflammation 3) Delayed clearance of glycosylated ferritin in patients with diabetes causes raised ferritin levels. In this premise, we studied the association between serum ferritin levels and microalbuminuria, glycemic control and dyslipidemia in type 2 diabetic patients. MATERIAL: A cross-sectional study was carried out at a tertiary hospital in northern India involving 152 patients of type 2 diabetes mellitus. Anthropometric measurements (weight, height), sample collection for basic laboratory parameters including complete blood count, kidney function tests, liver function tests, HbA1c, lipid profile, serum iron and ferritin levels, urinary albumin- creatinine ratio was done. A fundus examination was performed. Results were analyzed using descriptive statistics and making comparisons among various groups. Categorical data were summarized as proportions or percentages while discrete as mean. Chi-square test was used for testing associations. OBSERVATION: Mean serum ferritin levels were significantly higher in patients having microalbuminuria as against patients having normal urinary albumin- creatinine ratio (539 vs 292, p-value- 0.04). Patients having poor glycemic control (HbA1c > 7) had higher ferritin levels (p-value- 0.024). There was a near-significant association (p-value-0.06) between serum ferritin and triglyceride levels. More cases with raised serum ferritin had higher triglyceride levels. Patients having microalbuminuria had a higher prevalence of diabetic retinopathy (p-value- 0.003) and higher triglyceride levels (p-value- 0.041). CONCLUSION: Ferritin can act as a marker of diabetic nephropathy, poor glycemic control and dyslipidemia in type 2 diabetic patients. Our study, therefore, indicates that programs to prevent complications of diabetes would be more effective by placing greater emphasis on patients having higher ferritin levels.

Sexual health problems and health-seeking behavior of men who have sex with men in Agra City, Uttar Pradesh.

BACKGROUND: Men who have sex with men (MSM) are at high risk of acquiring sexually transmitted illnesses. The gross stigmatization of homosexuality and discrimination has always affected their health-seeking behavior. OBJECTIVES: The study aimed to assess the magnitude of sexual health problems, factors associated, and their health-seeking behavior. METHODS: Descriptive cross-sectional study was conducted in Agra city, Uttar Pradesh during December 2017 and November 2019 among a sample of 52 MSM. The Snowball technique of sampling was used to recruit the eligible subjects. Data were collected by interview and analyzed using MS excel. RESULTS: Overall prevalence of any sexual health problem in past 1 year was 71.2%. Anal/perianal problems (26.9%) and genital/oral vesicles (26.9%) were the most commonly encountered illnesses MSM who had all their sexual encounters with men (completely homosexual), those MSM who used to play both insertive and receptive roles, had 5 or more sexual partners, used condom irregularly had significantly higher chances of having sexual health problems. Most (70.3%) MSM sought treatment for their sexual health problem from an Allopathic doctor; 29.4% took treatment from a government health facility. The majority (94.1%) of them were reportedly satisfied with the health care facility. Most (79.4%) respondents preferred not to disclose their sexual behavior during interaction with their sexual health care provider. CONCLUSION: High prevalence of sexual health problems was found among MSM who engage in high-risk sexual behavior. MSM requires access to STIs screening. Behavior change communication is needed to improve their health-seeking behavior.

The Postural Effects on Electrical Activities of Heart in Apparently Healthy Young Adults.

Background The electrical activities of heart recorded as electrocardiogram (ECG) are mostly done in supine postures. The body postural changes have effects in these electrical activities in heart which needs to be properly recognized. Objective To find the variations in electrocardiogram during postural changes from supine to upright i.e. sitting and standing postures among apparently healthy young adults. Method A cross sectional study was carried out in Manipal College of Medical Sciences after the institutional ethical clearance. The apparently healthy 30 Nepalese male medical students between 18-25 years of age were enrolled. The electrocardiography was elicited in supine, sitting and standing postures in the participants after 5 minutes' interval between each procedure in each participant. Result The highest mean amplitudes of Q wave were seen in sitting postures (0.12±0.04 mm), R wave in standing postures (1.46±0.55 mm) and S wave also in standing postures (0.23±0.2 mm). The mean amplitudes of Q and S waves showed statistically significant difference when compared between supine and upright postures. The maximum QRS duration was found while sitting (0.08±0.01 ms)and maximum heart rate in standing posture (82.43±10.59/min). The mean comparison of heart rate was statistically highly significant when compared between supine and standing postures. The mean QRS frontal axis was comparatively increased while standing (64.30±39.29). Conclusion The electrical activities of heart vary during postural changes among apparently healthy young adults. These changes are most prominent when compared between supine and standing postures which urges for careful interpretation of electrocardiogram if it is done in upright postures.

Ultrafast Enhancement of Ferromagnetic Spin Exchange Induced by Ligand-to-Metal Charge Transfer.

We theoretically predict and experimentally demonstrate a nonthermal pathway to optically enhance superexchange interaction energies in a material based on exciting ligand-to-metal charge-transfer transitions, which introduces lower-order virtual hopping contributions that are absent in the ground state. We demonstrate this effect in the layered ferromagnetic insulator CrSiTe_{3} by exciting Te-to-Cr charge-transfer transitions using ultrashort laser pulses and detecting coherent phonon oscillations that are impulsively generated by superexchange enhancement via magneto-elastic coupling. This mechanism kicks in below the temperature scale where short-range in-plane spin correlations begin to develop and disappears when the excitation energy is tuned away from the charge-transfer resonance, consistent with our predictions.

Thenar lumps: a review of differentials.

Most soft-tissue lumps in the hand are benign, with ganglions being the commonest, but in the thenar region, solid soft-tissue masses are more common than a ganglion. In this review, we focus on soft-tissue lesions (neoplastic and non-neoplastic) presenting as a palpable lump in this region. A specific diagnosis can often be reached using ultrasonography and/or magnetic resonance imaging. Most of these lesions are managed in local hospitals or primary care, whereas some are referred to specialist centres. This review article will help both general and musculoskeletal radiologists to diagnose and characterise these lesions, provide a guide for further imaging, and provide an insight into imaging features that may need specific investigations such as core biopsy, tertiary referral, and further review at multidisciplinary meetings.

Effect of graded levels of soapnut (Sapindus mukorossi) shell powder on reproductive performance in broiler breeders.

OBJECTIVE: This study investigated the effects of soapnut (Sapindus mukorossi) shell powder (SSP) on serum hormone level, egg quality, semen characteristics and reproductive performance of broiler breeders fed with a maize-soybean meal based diet. METHODS: Ninety six female and twenty four male CARIBRO-VISHAL broiler breeders, 38-week old, were individually caged and randomly allocated to four treatment groups (24 female breeders/treatment and 6 male breeders/treatment): an un-supplemented control (T1) and three groups with 0.0176% SSP (group T2), 0.026% SSP (group T3) and 0.0528% SSP (group T4), to have supplementary saponin at 0, 50, 75, and 150 ppm, respectively, for 42 days. RESULTS: The results indicated that serum (p<0.001) and seminal plasma (p<0.05) testosterone level, semen volume (p<0.001), mass motility (p<0.001), and live spermatozoa count (p<0.001) was increased in groups T3 and T4 compared to T2 and control groups. Compared with control group, total sperm count was increased (p<0.001) and dead spermatozoa count was decreased (p<0.001) in SSP supplemented groups. Supplementation of SSP did not affected the quality of egg lay. Compared with control group, fertility (p<0.01) and hatchability (total eggs set and fertile eggs set) (p<0.001) were significantly improved in SSP supplemented groups with the highest improvement in T3 treatment group. Embryonic death was decreased (p< 0.001) in SSP supplemented groups compared to control; lowest embryonic death was recorded in T3 treatment group. CONCLUSION: Thus, it was concluded that dietary supplementation of 0.026% SSP (saponin equivalent 75 ppm) improved the reproductive performance of broiler breeders.

Microinvasion: A Clinical Dilemma.

Microinvasive oral squamous cell carcinoma (MIOSCC) is an early stage malignant tumour,showing invasion of the epithelial cells confined to the superficial lamina propria. This is matter of debate in respect to the clinical presentation, metastasis, therapeutic intervention and prognosis. A 32-year female reported to the department with chief complaint of wound and burning sensation in her left back region of lower gums. Clinical diagnosis of erosive oral lichen planus was made and topical steroid was started. The lesion clinically healed with the use of topical medicine. After stopping the medication the lesion recurred, following which, excisional biopsy was done. On histopathological evaluation diagnosis of microinvasive oral squamous cell carcinoma was made. Recurrence of similar symptom in the same site was seen 10 weeks later, which now showed features of moderate dysplasia. Clinical features of microinvasive oral squamous cell carcinoma resembles premalignant lesion, leading to difficulty in diagnosis, treatment and prognostic assessment. Thus, adequate representation of this entity is necessary.

Changes in the seroprevalence of cysticercosis in suspected patients in Chandigarh, India between 1998 and 2014: analysis of 17 years of data.

Changes in seroprevalence of cysticercosis diagnosed in Chandigarh, India between 1998 and 2014 were investigated by extraction and analysis of data from records held at the Postgraduate Institute of Medical Education and Research in Chandigarh. Among the total number of samples for which cysticercosis had been suspected during this period (N = 9650), 1716 (17·8%) were seropositive. Adults were more likely to be seropositive than children, and women were more likely to be seropositive than men. In addition to there being fewer patients with suspicion of cysticercosis over the data analysis period, the proportion of patients seropositive also reduced significantly. Despite these reductions, which are probably associated with improved infrastructure and sanitation within Chandigarh, and despite meat consumption being relatively rare in this area, the extent of cysticercosis in this population remains problematic. Further efforts should be made to reduce transmission of this infection, with particular emphasis on women. Such efforts should follow the One Health concept, and involve medical efforts (including diagnosis and treatment of T. solium tapeworm carriers), veterinary efforts directed towards meat inspection and prevention of infection of pigs, and environmental health and sanitation engineers (to minimize environmental contamination with human waste).

Cocaine Abuse: An Unusual Association.

Cocaine addiction is a common problem in the adolescent and the young adults, pharmacologic interventions to reverse the effects of which do not exist. Neurological complications of cocaine abuse, such as seizures, headache, ischemic or hemorrhagic stroke, or subarachnoid hemorrhage, can be disastrous as a result of uncontrolled vasoconstriction and vasculitic damage. The lone occurrence of subdural hematoma in the absence of any other intracranial hemorrhagic complication is rarely seen in patients of cocaine abuse. We wish to share our experience of one such patient who presented to us with an unusual combination of the widespread cerebral infarction and subdural hematoma.

Tolerance of activated pathogenic CD4+ T cells by transcriptional targeting of dendritic cells.

We have recently shown that targeted expression of myelin oligodendrocyte glycoprotein (MOG) to dendritic cells with self-inactivating-lentivirus vectors induces antigen-specific tolerance in naive antigen-specific CD4+ T cells and protects mice from experimental autoimmune encephalomyelitis (EAE). In the present study, we demonstrate that this approach also induces tolerance of activated antigen-specific CD4+ T cells and completely protects mice from passive EAE induction. Tolerance induction did not correlate with the depletion of the preactivated antigen-specific CD4+ T cells. However, upon isolation and in vitro re-stimulation at day 6 after adoptive transfer the MOG-specific CD4+ T cells from the non-tolerized mice produced large amounts of inflammatory cytokines, whereas those from tolerized mice did not. This unresponsiveness correlated with the upregulation of regulatory molecules associated with anergy and regulatory T cells (Tregs). The in vivo depletion of Tregs resulted in EAE susceptibility of the tolerized animals, suggesting that these cells have indeed a role in tolerance induction/maintenance.

Oriented polyvinylidene fluoride-trifluoroethylene (P(VDF-TrFE)) films by Langmuir-Blodgett deposition: a synchrotron X-ray diffraction study.

Langmuir-Blodgett films of polyvinylidene fluoride trifluoroethylene - P(VDF-TrFE)-copolymers possess substantially improved electrocaloric and pyroelectric properties, when compared with conventionally spin-cast films. In order to rationalize this, we prepared single-layered films of P(VDF-TrFE) (70 : 30) using both deposition techniques. Grazing incidence wide-angle X-ray scattering (GIWAXS), reveals that Langmuir-Blodgett deposited films have a higher concentration of the ferroelectric ß-phase crystals, and that these films are highly oriented with respect to the substrate. Based on these observations, we suggest alternative means of deposition, which may substantially enhance the electrocaloric effect in P(VDF-TrFE) films. This development has significant implications for the potential use of P(VDF-TrFE) in solid-state refrigeration.

Prevalence of hepatic osteodystrophy and vitamin D deficiency in cirrhosis.

BACKGROUND: Hepatic osteodystrophy (HO) is a major complication of cirrhosis. However, the prevalence of HO in a general cirrhotic patient population is not well defined as previous studies were in single aetiology or pre-liver transplant patients. AIMS: The aims of this study were to investigate the prevalence of HO and vitamin D deficiency in patients with cirrhosis of mixed aetiology and disease severity and to determine the risk factors for HO. METHODS: This is a single-centre cross-sectional study of all patients newly diagnosed with cirrhosis between September 2009 and December 2012. All patients underwent bone mineral density assessment using dual energy X-ray absorptiometry within 3 months of diagnosis. Demographic and biochemical factors, severity of underlying liver disease, previous fragility fractures, smoking status and alcohol use were collected on diagnosis. Logistic regression analysis was used to assess risk factors for HO. RESULTS: Among the 406 patients (67% males), the median (range) age was 56 years (21-85) and most (84%) were Childs-Pugh A or B with a median (range) model for end-stage liver disease score of 11 (5-40). Alcohol (41%) was the most common underlying aetiology. The prevalence of HO and vitamin D deficiency (≤50 nmol/L) was 56% and 54%, respectively, and previous fragility fractures had occurred in 3%. Increasing age (odds ratio (95% confidence interval): 1.49 per 10 years (1.02-2.18), P = 0.04), excessive alcohol intake (2.34 (1.03-5.32), P = 0.04) and lower body mass index (0.92 per kg/m2 (0.87-0.98), P = 0.009) were independent risk factors for HO. CONCLUSION: There is a high prevalence of HO and vitamin D deficiency in patients with cirrhosis at presentation irrespective of disease severity or underlying aetiology.

Evaluation of Different Root Canal Obturation Methods in Primary Teeth Using Cone Beam Computerized Tomography.

OBJECTIVE: To evaluate the efficiency of 3 different obturation techniques; motor driven lentulospiral, hand held lentulospiral and reamer in primary anterior teeth and presence of voids by analyzing with CBCT. STUDY DESIGN: 60 single rooted extracted primary teeth were prepared and obturated with ZOE paste. Obturation methods were divided into three groups. GROUP I- motor driven lentulo spiral, II- hand held lentulo spiral and III- reamer. Obturated samples were scanned in CBCT machine and images were analysed for the evaluation of their quality of fill comprising presence, location and size of voids. RESULTS: At all the locations, Group II had maximum number of sites with voids when compared to other two groups. However, statistically significant intergroup differences were observed only at coronal third location (p=0.001) and overall assessment (p=0.003). Number of affected sites revealed the difference between Groups I and II be significant statistically (p=0.002) while the difference between Groups I and III and between Groups II and III was not significant statistically (p>0.05). At all the locations as well as for combined assessment, Group I had minimum mean size of the void. CONCLUSION: Motor driven lentulo spiral technique demonstrated more number of optimal fills with fewer voids when compared to hand held lentulo spiral technique and reamer.

Takotsubo cardiomyopathy.

Acute and rapidly reversible left ventricular dysfunction may be triggered by various emotional and physical insults. The most common precipitant being the death of a close family member but the other reported precipitants include court appearance, fear of a procedure, arguments and surprise parties and reunions. This entity is now well known as stress cardiomyopathy or Takotsubo cardiomyopathy. We report a case of rapidly reversible left ventricular dysfunction following attempted suicide by hanging.

Ibuprofen degradation by mixed bacterial consortia: Metabolic pathway and microbial community analysis.

Degradation of ibuprofen, one of the most consumed drugs globally, by a mixed bacterial consortium was investigated. A contaminated hospital soil was used to enrich a bacterial consortium possessing the ability to degrade 4 mg/L ibuprofen in 6 days, fed on 6 mM acetate as a supplementary carbon source. Maximum ibuprofen degradation achieved was 99.51%, and for optimum ibuprofen degradation modelled statistically, the initial ibuprofen concentration, and temperature were determined to be 0.515 mg/L and 35 °C, respectively. The bacterial community analyses demonstrated an enrichment of Pseudomonas, Achromobacter, Bacillus, and Enterococcus in the presence of ibuprofen, suggesting their probable association with the biodegradation process. The biodegradation pathway developed using open-source metabolite predictors, GLORYx and BioTransformer suggested multiple degradation routes. Hydroxylation and oxidation were found to be the major mechanisms in ibuprofen degradation. Mono-hydroxylated metabolites were identified as well as predicted by the bioinformatics-based packages. Oxidation, dehydrogenation, super-hydroxylation, and hydrolysis were some other identified mechanisms.