Author Response.

How to cite this article: Vijayakumar M, Selvam V, Renuka MK, Rajagopalan RE. Author Response. Indian J Crit Care Med 2024;28(5):515.

Author Response.

How to cite this article: Vijayakumar M, Selvam V, Renuka MK, Rajagopalan RE. Author Response. Indian J Crit Care Med 2024;28(5):512.

Convolutional neural network deep learning model accurately detects rectal cancer in endoanal ultrasounds.

BACKGROUND: Imaging is vital for assessing rectal cancer, with endoanal ultrasound (EAUS) being highly accurate in large tertiary medical centers. However, EAUS accuracy drops outside such settings, possibly due to varied examiner experience and fewer examinations. This underscores the need for an AI-based system to enhance accuracy in non-specialized centers. This study aimed to develop and validate deep learning (DL) models to differentiate rectal cancer in standard EAUS images. METHODS: A transfer learning approach with fine-tuned DL architectures was employed, utilizing a dataset of 294 images. The performance of DL models was assessed through a tenfold cross-validation. RESULTS: The DL diagnostics model exhibited a sensitivity and accuracy of 0.78 each. In the identification phase, the automatic diagnostic platform achieved an area under the curve performance of 0.85 for diagnosing rectal cancer. CONCLUSIONS: This research demonstrates the potential of DL models in enhancing rectal cancer detection during EAUS, especially in settings with lower examiner experience. The achieved sensitivity and accuracy suggest the viability of incorporating AI support for improved diagnostic outcomes in non-specialized medical centers.

The ISCCM/IAPC Position Statement: Ending the Sisyphean Struggle to Practice Ethical End-of-life Care in India.

Rajagopalan RE, Kapadia F. The ISCCM/IAPC Position Statement: Ending the Sisyphean Struggle to Practice Ethical End-of-life Care in India. Indian J Crit Care Med 2024;28(3):189-190.

Surgical outcomes of minimally invasive trephine surgery for pilonidal sinus disease with and without laser therapy: a comparative study.

BACKGROUND: Over the last decades, novel therapeutic options have emerged for the surgical treatment of pilonidal sinus disease (PSD). The aim of this study was to evaluate the outcomes of trephine/pit excision surgery with or without laser therapy in patients with PSD. METHODS: A retrospective cohort study was conducted at a large tertiary medical center, including all adult patients with PNS who underwent trephine surgery with/without laser therapy between 2016 and 2021[AUTHORS TO INSERT MONTH]. Propensity score matching was used to address confounding factors, and the primary outcome was the 1-year recurrence rate. RESULTS: The study included 221 patients with PSD, with a mean age of 23.73 years (87.7% male). In the unmatched cohort (130 trephine surgery alone, 91 trephine surgery + laser therapy), significant differences were observed in mean age (23 vs. 25 years; p < 0.01)[AUTHROS TO USE MEDIAN PLUS RANGE OR ADD SD] and surgeons' experience (p = 0.014). Propensity score matching was applied to overcome confounding factors, resulting in a matched cohort including 73 patients in each group. The addition of laser therapy demonstrated a significantly lower recurrence rate (8.2% vs. 32.9%; p < 0.001) compared to pit excision without laser therapy. Logistic regression analysis showed that the addition of laser was significantly associated with a lower risk for recurrence (OR 0.23; 95% CI 0.089-0.633; p < 0.01). CONCLUSION: The incorporation of laser therapy along with trephine/pit excision surgery significantly reduces the recurrence rate in patients with PNS. Further prospective studies are needed to confirm our findings.

The possible involvement of sema3A and sema4A in the pathogenesis of multiple sclerosis.

BACKGROUND: Immune semaphorins are widely accepted to have functional impact on autoimmune diseases. OBJECTIVES: To assess the status of sema3A and sema4A in the pathogenesis of Multiple Sclerosis (MS). RESULTS: Sema3A expression on (T regulatory cells)Tregs was decreased in MS patients, compared to healthy controls (35.85 ± 16.7% vs 88.27 ± 3.8%; p ≤ 0.001). Serum levels of sema3A were decreased in MS patients 2.95 ± 0.43 vs 18.67 ± 5.7 ng/ml in healthy individuals; p ≤ 0.001. Sema4A serum levels were increased in MS patients compared to healthy individuals (12.99 ± 8.6 vs 5.83 ± 3.91 ng/ml; p ≤ 0.001). Sema3A and sema4A serum levels were found to be in negative/positive correlation with MS disease severity (rs = 0.62, rs = -0.49, respectively). CONCLUSION: We show that sema3A is a regulatory molecule in MS, whereas sema4A is a stimulatory one. Targeting sema3A and sema4A could become a potential therapeutic approach in MS.

Laparoscopic fixation of volvulus by extra-peritonealization: a case series.

BACKGROUND: Volvulus is one of the leading causes of colonic obstruction with a high recurrence rate following endoscopic decompression. Although colonic resection remains the treatment of choice, it is often associated with significant morbidity and mortality, especially in elderly patients. Colonic fixation with extra-peritonealization has been suggested as an alternative to colonic resection. The aim of this study was to evaluate the surgical outcomes of patients with colonic volvulus in our initial experience with this procedure. METHODS: A retrospective analysis of a prospectively maintained database of all patients who underwent colonic extra-peritonealization for volvulus between January 2016 and April 2021 in Sheba medical center (Ramat-Gan, Israel) was performed. Patients' demographics, clinical, peri-operative and post-operative data were recorded and analyzed. RESULTS: One hundred and thirty nine patients were admitted due to acute colonic volvulus, 48 of whom were treated surgically. Eleven patients underwent extra-peritonealization of the sigmiod or cecum during the study period. Mean age was 64.5 years. Six patients (54.55%) were males. Seven patients (63.63%) presented with sigmoid volvulus and 4 (36.36%) with cecal volvulus. Median American Society of Anesthesiologists (ASA) class was 3 (range 2-4). One patient (9.09%) was required urgent surgery. The majority of patients was operated on using a laparoscopic approach (10 patients, 90.9%). Median length of stay was 3 days (range 1-6 days) and no post-operative complications or readmissions within 30 days after surgery were recorded. Median length of follow-up was 283 days (range 21-777 days). During the follow-up period, three patients (27.27%) presented with recurrent volvulus and required an additional surgical intervention with colonic resection. Of the patients with volvulus recurrence, one patient (9.09%) required an urgent surgical intervention. CONCLUSIONS: Extra-peritonealization of colonic volvulus is feasible and safe. Although recurrence rates are fairly high, the low morbidity associated with the procedure makes it an appealing alternative to colonic resection, especially in patients with high risk for post-operative complications.

CPIS Lung Ultrasound and the Erratic March toward Diagnostic Certainty in VAP.

How to cite this article: Rajagopalan RE. CPIS Lung Ultrasound and the Erratic March toward Diagnostic Certainty in VAP. Indian J Crit Care Med 2021;25(3):255-257.

Utility of different positron emission tomography/computed tomography tracers in the evaluation of incidentally detected dual malignancies: An experience from a tertiary care center.

Multiple primary malignancies in a cancer patient are not a rare occurrence. The most common presentation of multiple primary malignancies is dual malignancies. The usefulness of different positron emission tomography (PET)/computed tomography (CT) tracers in the evaluation of dual synchronous primary malignancies is not well documented. Here, we present a case series, where two patients, referred for PET/CT, after being diagnosed with one primary malignancy were found to be having a second primary malignancy, diagnosed incidentally in PET/CT, further validated by PET/CT with another tracer.

Magnetic imaging defecography results are comparable to high-resolution manometry and conventional X-ray defecography in the assessment of functional pelvic floor disorders.

BACKGROUND: X-ray defecography or magnetic resonance defecography (MRD) and high-resolution anorectal manometry (HR-ARM) are essential for the diagnosis of pelvic floor disorders (PFD). However, there is only scarce information available about the accuracy of MRD in the functional assessment of the pelvic floor. The aim of this study was to examine the accuracy of MRD in the diagnosis of pelvic floor disorders by examining the intra-test agreement with x-ray defecography and HR-ARM in patients with PFD. METHODS: The study population included adults referred to our institution in January 2018-February 2020 for MRD as part of their evaluation of PFD. The MRD results were compared with X-ray defecography and HR-ARM. RESULTS: Forty-two patients were included in the study (36 female, 86%, mean age 56.9 years ± 15.8, range 19-86 years). When compared to X-ray defecography, the sensitivity of MRD for the evaluation of normal rest and squeeze pressures was high (0.83 and 1, respectively). High sensitivity rates were observed for the detection of pelvic organ prolapse and pelvic floor dyssynergia (0.84-1). When compared to HR-ARM, the sensitivity of MRD for the evaluation of squeeze and dyssynergia was very good (0.92and 1, respectively), and good for the evaluation of rest pressure (0.6). Inter-test agreement was high (0.5, 0.6, 0.6 for rest, squeeze and dyssynergia). Excellent rates of sensitivity as well as almost perfect intra-test agreement was found between abnormal balloon expulsion test and the diagnosis of dyssynergia and pelvic organ prolapse on MRD (1, 0.81). CONCLUSIONS: This study demonstrated substantial diagnostic agreement between HR-ARM and MRD in the diagnosis of pathological etiologies for functional pelvic floor disorders, mainly obstructed defecation syndrome.

The efficacy of sacral neuromodulation in the treatment of low anterior resection syndrome: a systematic review and meta-analysis.

BACKGROUND: Sacral neuromodulation (SNM) has become one of the main treatment options in patients with fecal incontinence. The aim of this study was to determine the efficacy of sacral neuromodulation in the treatment of low anterior resection syndrome (LARS). METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search was conducted using the Pubmed, Embase, Ovid, and Cochrane databases, restricted to the English language and to articles published from 2000 to November 2018. RESULTS: A total of 434 articles on the efficacy of SNM in the treatment of LARS were retrieved, and 13 studies were included in the final analysis, with a total of 114 patients treated with SNM for LARS The overall success rate excluding study heterogeneity was 83.30% [95% CI (71.33-95.25%)]. Improvement in anal continence was seen in several clinical and functional parameters, including the Wexner Score [10.78 points, 95% CI (8.55-13.02), p < 0.0001], manometric maximum resting pressure [mean improvement of 6.37 mm/Hg, 95% CI (2.67-10.07), p = 0.0007], maximum squeeze pressure [mean improvement of 17.99 mm/Hg, 95% CI (17.42-18.56), p < 0.0001] and maximum tolerated volume [mean improvement of 22.74 ml, 95% CI (10.65-34.83), p = 0.0002]. Quality of life questionnaires also demonstrated significant improvement in patients' quality of life, but were reported only in a small group of included patients. CONCLUSIONS: SNM significantly improves symptoms and quality of life in patients suffering from fecal incontinence following low anterior resection.

HDL-cholesterol elevation associated with fingolimod and dimethyl fumarate therapies in multiple sclerosis.

BACKGROUND: Patients with Multiple Sclerosis (PwMS) display altered lipoproteins levels and function, which seem to affect disease risk and progress. Whether disease-modifying therapies affect the lipoprotein profile in PwMS has scarcely been studied. OBJECTIVE: The study aims to assess whether fingolimod and dimethyl fumarate (DMF) affect lipoproteins in PwMS. METHODS: We compared retrospectively the blood lipoprotein levels of 29 fingolimod-treated and 41 DMF-treated patients before and after 3 and 12 months of therapy. Patients treated with cholesterol-reducing medications were not included. Data on weight change and disease activity during 1-year follow-up were obtained. RESULTS: HDL level, HDL/LDL ratio and HDL/total cholesterol ratio were increased in both treatment groups after 3 months' therapy and sustained, with no change in LDL or triglycerides. While at baseline only 26% of patients met the recommended minimum of HDL 60 mg/dl, after 3 months' therapy, 43% of fingolimod-treated and 47% of DMF-treated patients reached the recommended level. The majority of patients had no weight reduction. CONCLUSIONS: Fingolimod and DMF therapies are associated with a specific increase in HDL in PwMS. Further studies are required to validate these findings and their potential implication as biomarker of reduced inflammatory state and/or reduced risk of neurodegeneration or cardiovascular comorbidity.

Is there an association between mesenteric panniculitis and lymphoma? A case control analysis.

AIM: To determine the prevalence and association of mesenteric panniculitis (MP) in a group of patients with non-Hodgkin's lymphoma (NHL) compared to control group. MATERIALS AND METHODS: We retrospectively evaluated computed tomography (CT) and combined positron-emission tomography (PET) with CT examinations of a total of 166 patients who were diagnosed with NHL over a period of 5 years (2008-2013). The control group consisted of 332 subjects who were matched for gender and age at the time period the examinations were performed on the study group. A combination of radiological signs and absence of 2-[18F]-fluoro-2-deoxy-d-glucose (FDG)-uptake was used to establish the diagnosis of MP and distinguish it from the involvement of mesentery by lymphoma. RESULTS: MP was identified in three patients (prevalence 1.8%) from the study group as compared to seven subjects out of 332 (2.1%) in the control group (p=0.556). During the course of follow-up no changes in the imaging features of MP were seen in either group. Additionally, 27 (16.2%) patients from the study group were found to have changes in the mesentery, which were attributed to the involvement of the mesentery in the primary disease. CONCLUSION: The prevalence of MP among patients with NHL was found to be 1.8%, which corresponds to the range of its prevalence in the general population. This is contrary to the proposition that MP is associated with NHL.

Early clinical prediction of neurological outcome following out of hospital cardiac arrest managed with therapeutic hypothermia.

BACKGROUND: Therapeutic hypothermia (TH) may improve neurological outcome in comatose patients following out of hospital cardiac arrest (OHCA). The reliability of clinical prediction of neurological outcome following TH remains unclear. In particular, there is very limited data on survival and predictors of neurological outcome following TH for OHCA from resource-constrained settings in general and South Asia in specific. OBJECTIVE: The objective was to identify factors predicting unfavorable neurological outcome at hospital discharge in comatose survivors of OHCA treated with hypothermia. DESIGN: Retrospective chart review. SETTING: Urban 200-bed hospital in Chennai, India. METHODS: Predictors of unfavorable neurological outcome (cerebral performance category score [3-5]) at hospital discharge were evaluated among patients admitted between January 2006 and December 2012 following OHCA treated with TH. Hypothermia was induced with cold intravenous saline bolus, ice packs and cold-water spray with bedside fan. Predictors of unfavorable neurological outcome were examined through multivariate exact logistic regression analysis. RESULTS: A total of 121 patients were included with 106/121 (87%) experiencing the unfavorable neurological outcome. Independent predictors of unfavorable neurological outcome included: Status myoclonus <24 h (odds ratio [OR] 21.79, 95% confidence interval [CI] 2.89-Infinite), absent brainstem reflexes (OR 50.09, 6.55-Infinite), and motor response worse than flexion on day 3 (OR 99.41, 12.21-Infinite). All 3 variables had 100% specificity and positive predictive value. CONCLUSION: Status myoclonus within 24 h, absence of brainstem reflexes and motor response worse than flexion on day 3 reliably predict unfavorable neurological outcome in comatose patients with OHCA treated with TH.

Why not the best? Social anxiety symptoms and perfectionism among Israeli Jews and Arabs: a comparative Study.

BACKGROUND: Social Anxiety Disorder (SAD) has been repeatedly shown to be very prevalent in the Western society and is characterized by low self-esteem, pessimism, procrastination and also perfectionism. Very few studies on SAD have been done in the Middle East or in Arab countries, and no study tackled the relationship between social anxiety symptoms and perfectionism in non-Western samples. METHODS: We examined social anxiety symptoms and perfectionism in a group of 132 Israeli Jewish (IJ) and Israeli Arab (IA) students. Subjects completed the Liebowitz Social Anxiety Scale (LSAS), the Multidimensional Perfectionism Scale (MPS), the Negative Automatic Thoughts Questionnaire (ATQ-N), the Positive Automatic Thoughts Questionnaire (ATQ-P) and a socio-demographic questionnaire. RESULTS: The rate of SAD in our sample according to a LSAS score of 60 or more was 17.2% (IJ=13.8%, IA=19%, ns). The correlation between perfectionism and the LSAS was high in both groups, and in particular in the IJ group. The IA group had higher scores of social avoidance, of ATQ-P and of two of the MPS subscales: parental expectations and parental criticism. Concern over mistakes and negative automatic thoughts positively predicted social fear in the IJ group, whereas in the IA group being female, religious and less educated positively predicted social fear. Negative automatic thoughts and age positively predicted social avoidance in the IJ group. In general, the IJ and IA subjects showed higher social anxiety, higher ATQ-N scores and lower parental expectations as compared with non-clinical US samples. CONCLUSIONS: Social anxiety symptoms and perfectionism are prevalent in Arab and Jewish students in Israel and seem to be closely related. Further studies among non-western minority groups may detect cultural influences on social anxiety and might add to the growing body of knowledge on this intriguing condition.

Perineal stapled prolapse resection (PSPR) in elderly patients for external rectal prolapse: early experience.

BACKGROUND: Full-thickness rectal prolapse in frail elderly patients is often treated by a perineal approach with considerable attendant morbidity. We report our preliminary results of the perineal stapled prolapse resection (PSPR) technique for resection of full-thickness external rectal prolapse using a new reloadable Contour(®) Transtar™ stapler (Ethicon Endo-Surgery) device. METHODS: Fourteen elderly high-risk patients with an external prolapse up to 10 cm in length were treated between April 2010 and October 2011, and operative factors, outcome and recurrence rates were assessed. RESULTS: There were no intraoperative difficulties and no perioperative morbidity. The median operating time was 35 min (range 25-45 min) with a median hospital stay of 3 days (range 3-5 days). Four patients developed early recurrence over a median follow-up of 32 months (range 25-41 months). CONCLUSIONS: PSPR is safer, faster and easier to perform than other conventional perineal prolapse procedures and is suitable for elderly, high-risk patients for whom an abdominal approach under general anesthesia is not advisable.

Percutaneous cholecystostomy in critically ill patients with acute cholecystitis: complications and late outcome.

AIM: To evaluate the outcome of percutaneous cholecystostomy in critically ill patients with acute cholecystitis. MATERIALS AND METHODS: The study group included critically ill patients who underwent percutaneous cholecystostomy for acute cholecystitis at a tertiary medical centre in 2007-2011. Data on complications, morbidities, surgical outcome, and imaging findings were collected from the medical files and radiology information system. RESULTS: There were 48 women (59.3%) and 33 men (40.7%), with a median age of 82 years (range 47-99 years). Seventy-one (88%) had calculous cholecystitis and 10 (12%), acalculous cholecystitis. The drain was successfully inserted in all cases with no immediate major procedural complications. Fifteen patients (18.5%) died in-hospital within 30 days, mainly (93%) due to septic shock (14/15), another 20 patients (24.7%) died during the study period of unrelated co-morbidities. Of the remaining 46 patients, 36 (78.2%) had surgical cholecystectomies. In patients with acalculous cholecystitis, the drain was removed after cessation of symptoms. Transcystic cholangiography identified five patients with additional stones in the common bile duct. They were managed by pushing the stones into the duodenum via the cystostomy access, sparing them the need for surgical exploration. CONCLUSIONS: Early percutaneous gallbladder drainage is safe and effective in critically ill patients in the acute phase of cholecystitis, with a high technical success rate. Surgical results in survivors are better than reported in patients treated surgically without drainage. Bile duct stones can be eliminated without creating an additional access.

Prevalence of obesity among Arab school children in Nazareth, Israel: comparison with national (Jewish) and international data.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: Lack of published data. Absence of Ethnic specific data. Lack of focus on obesity prevention in Arab schools. WHAT THIS STUDY ADDS: First set of data on obesity for Arab children. Data will be used as reference data. Alert health/school official for intervention. SUMMARY: Objective The objective is to produce the first set of obesity prevalence data and use the data as reference values of body mass index (BMI) trends for Arab children in Israel and compare with Jewish and international data. Methods A prevalence study was carried out in 2009 in which 4130 children aged 6-12, were selected from eight Arab sector schools representing the Nazareth Municipality. Height, weight and BMI measurements were obtained and presented by age, mean age, size, weight, gender and percentile. Appropriate epidemiological and statistical methods used for comparison. Results The obesity and overweight prevalence rates in Arab children by age ranges from 0% to 2.6% and 0% to 11.2%, respectively. Comparison with international and Jewish data revealed differences in almost all age groups but higher rates in Arabs, especially boys. Discussion The higher rates/trends in Arab children may be explained by more Arab women entering the workforce, increase in single-parent families and changes in food and physical activity environments. Conclusion Based on our data, we recommend either an ethnic-specific BMI reference curves and/or inclusion of Arab data in the Israeli data system. Research need to focus on reasons for the increase and interventions to reverse/slow the trend.

Live imaging of induced and controlled DNA double-strand break formation reveals extremely low repair by homologous recombination in human cells.

DNA double-strand breaks (DSBs), the most hazardous DNA lesions, may result in genomic instability, a hallmark of cancer cells. The main DSB repair pathways are non-homologous end joining (NHEJ) and homologous recombination (HR). In mammalian cells, NHEJ, which can lead to inaccurate repair, predominates. HR repair (HRR) is considered accurate and is restricted to S, G2 and M phases of the cell cycle. Despite its importance, many aspects regarding HRR remain unknown. Here, we developed a novel inducible on/off switch cell system that enables, for the first time, to induce a DSB in a rapid and reversible manner in human cells. By limiting the duration of DSB induction, we found that non-persistent endonuclease-induced DSBs are rarely repaired by HR, whereas persistent DSBs result in the published HRR frequencies (non-significant HR frequency versus frequency of ∼10%, respectively). We demonstrate that these DSBs are repaired by an accurate repair mechanism, which is distinguished from HRR (most likely, error-free NHEJ). Notably, our data reveal that HRR frequencies of endonuclease-induced DSBs in human cells are >10-fold lower than what was previously estimated by prevailing methods, which resulted in recurrent DSB formation. Our findings suggest a role for HRR mainly in repairing challenging DSBs, in contrast to uncomplicated lesions that are frequently repaired by NHEJ. Preventing HR from repairing DSBs in the complex and repetitive human genome probably has an essential role in maintaining genomic stability.