Evolution of Metabolic Syndrome in Newly Diagnosed Type 2 Diabetes Mellitus Asian-Indian Patients Over the Last 15 Years using Adult Treatment Panel III of the National Cholesterol Education Program, World Health Organization, and International Diabetes Federation Criterion.

AIM: A retrospective observational study was undertaken to assess the changing trends in the incidence of metabolic syndrome (MetS) in Asian-Indian patients with newly diagnosed type 2 diabetes (T2D) using Adult Treatment Panel III of the National Cholesterol Education Program (NCEP-ATP III), World Health Organization (WHO), and the International Diabetes Federation (IDF) criteria. The overall and gender-wise pattern of MetS and its components were also evaluated. MATERIALS AND METHODS: Newly diagnosed T2D patients (n = 10,950)visiting Dr Panikar's Diabetes Care Centre from 2004 to 2019 with retrievable electronic medical records were selected. The incidence of MetS in these patients was studied using NCEP-ATP III, WHO, and IDF criteria in three separate timelines, namely, group I (2004-2008), group II (2009-2013), and group III (2014-2019). Overall and gender-wise, the incidence of various components of the MetS was also studied and compared across the three groups. All data were analyzed by using the Statistical Software Statistical Package for the Social Sciences (SPSS) version 10.0. Continuous variables were summarized by the number of observations (mean, standard deviation or median with minimum and maximum) and categorical values (calculating frequencies with percentages). Chi-square was used to estimate the incidence of MetS using different criteria and gender-wise patterns of the MetS components for the three periods. Other variables, such as mean body mass index (BMI), were assessed by applying variance analysis (ANOVA test). All values were reported based on a two-sided ANOVA test, and all the statistical tests were interpreted at a 5% level of significance. RESULTS: In the current study, the overall incidence of MetS observed among the study population was 80.9, 65.4, and 69.8% using NCEP-ATP III, WHO, and IDF criteria, respectively. The incidence of MetS across the three timelines (i.e., from 2004 to 2019) with all the diagnostic criteria showed a steady increase. An analysis of the individual components of MetS revealed a high incidence of central obesity across all subgroups, followed by hypertension and dyslipidemia. Central obesity was prevalent in nearly 85.9% of patients in 2014-2019 vs 78.6% in the 2004-2008 subgroup. Similarly, the incidence of hypertension and overall dyslipidemia [i.e., high triglycerides (TGs) and low high-density lipoprotein-cholesterol (HDL-C)] was 77.8% and 68.2% in the former vs 67.9% and 59.6% in the latter, respectively. The incidence of all three MetS components, along with fasting sugar, showed a statistically significant and progressive increase over the years, with prevalence in group III (2014-2019) being the highest. Women were found to be more centrally obese and more dyslipidemic compared to men, whereas men were found to be more hypertensive. CONCLUSION: The study shows a high incidence of MetS in Asian-Indian patients with newly diagnosed T2D. The incidence of MetS was significantly higher with the NCEP-ATP III diagnostic criteria than with WHO and IDF criteria. A steady rise in the incidence of MetS was observed over the study period of 2004-2019. Among the components of MetS, the incidence of central obesity, elevated TG levels, and low HDL-C were found to be higher in the female population than in males, whereas the incidence of hypertension was higher in males. Stringent lifestyle measures, along with appropriate pharmacological management, might help mitigate the risks associated with MetS.

Immunomodulation by mesenchymal stem cells during osteogenic differentiation: Clinical implications during bone regeneration.

Critical bone defects resulting in delayed and non-union are a major concern in the field of orthopedics. Over the past decade, mesenchymal stem cells (MSCs) have become a promising frontier for bone repair and regeneration owing to their high expansion rate and osteogenic differentiation potential ex vivo. MSCs have also long been associated with their ability to modulate immune response in the recipients. These can even skew the immune response towards pro-inflammatory or anti-inflammatory type by sensing their local microenvironment. MSCs adopt anti-inflammatory phenotype at bone injury site and secrete various immunomodulatory factors such as IDO, NO, TGFß1 and PGE-2 which have redundant role in osteoblast differentiation and bone formation. As such, several studies have also sought to decipher the immunomodulatory effects of osteogenically differentiated MSCs. The present review discusses the immunomodulatory status of MSCs during their osteogenic differentiation and summarizes few mechanisms that cause immunosuppression by osteogenically differentiated MSCs and its implication during bone healing.

An integrated multi-criteria decision-making framework for the selection of sustainable biodegradable polymer for food packaging applications.

Manifold aspects, such as the booming market for superior quality food items with increased shelf life and the escalating concern to mitigate plastic trash due to plastic packaging have motivated researchers and food industrialists to explore sustainable eco-friendly packaging solutions extensively. Biodegradable polymers are being rigorously investigated to replace conventional plastics that are toxic, non-biodegradable, and detrimental to the marine ecosystem. The scientific methodology for the prudent selection of biodegradable polymer among the frequently used biopolymers for food packaging is being reported here. The data were extracted from the available literature. A hybrid multi-criteria decision-making framework has been developed to address the problem of material selection owing to the multiple conflicting criteria involved. Assignment of equal weights to primary criteria was selected to establish the criteria weights. Different decision-making techniques (weighted sum method (WSM), weighted product method (WPM), weighted aggregated sum product assessment method (WASPAS), and technique for order of preference by similarity to ideal solution (TOPSIS)) were used for the comparative analysis. Thereon, the different ranks obtained for each alternative were aggregated using the degree of membership technique. The robustness of the solution was checked using sensitivity analysis which was conducted by varying weights of importance using the entropy method, the CRITIC method, and the equal weights to secondary criteria. The analysis reported polylactic acid (PLA) as the most reliable polymer for food packaging applications. The sensitivity analysis concluded that the solution was without prejudice, and water vapor permeation rating was the most critical decision criterion in deciding the optimal polymer.

Dental pulp stem cell secretome ameliorates d-galactose induced accelerated aging in rat model.

Advancing age is associated with several diseases and disorders due to multiorgan atrophy. The increasing proportion of elderly humans demands the identification of means to counteract aging and age-associated disorders. There is an increased depletion of stem cells in the aged organs, resulting in their inability to repair the damage and hence organ degeneration. Stem cell therapy has been implicated in counteracting aging and shown promise. However, the use of stem cells encounters several side effects and complications such as handling and storage of the cells for transplantation purpose. Stem cells secretome has proven to be of significant importance in a variety of disorders. In this study, we have shown that secretome derived from dental pulp stem cells (DPSCs) can reverse the age-associated degeneration induced by chronic exposure to d-galactose in a rat model. The secretome was able to increase muscle grip strength and animal activity. Secretome also improved the kidney function and hepatic biochemistry similar to healthy controls as evaluated by renal function test and Fourier-transform infrared spectroscopy. We also showed that secretome reduced the levels of monoamine oxidase and acetylcholinesterase in the brain and liver, indicating aging reversal. Finally, proteomic profiling of DPSCs secretome revealed the presence of 13 proteins which have antiaging functions. Thus, our study provides first proof of concept that DPSCs secretome can render protection against d-galactose induced accelerated aging.

A Clinico-Epidemiological Study of Neurofibromatosis Type 1 and Its Relation to Quality of Life: A Cross-Sectional Study From India.

INTRODUCTION:  Neurofibromatosis type 1 (NF1) is an inherited neuroectodermal abnormality with multisystem effects, which can have heavy psychological and physical burdens, especially in countries like India, wherein skin disease is significantly stigmatized. This study was performed to understand the clinical and epidemiological trends of NF1 at a tertiary care center in India and evaluate the association between clinical severity and quality of life in these patients. METHODS:  We conducted a cross-sectional study of 40 patients with NF1 over a period of two years at a tertiary hospital in western India. After obtaining consent, demographic and clinical information was collected from the patients and recorded in a pre-designed proforma. Quality of life was assessed by a validated Dermatology Life Quality Index (DLQI) questionnaire in languages understood by the patients and subsequently analyzed. RESULTS:  This study included 40 patients at a mean age of 28.6 years, with a slight male predominance. The most frequently occurring lesions were café-au-lait macules, followed by neurofibromas and intertriginous freckling. The mean DLQI score was 12.35, implying a large effect on most patients' lives. Questions related to self-consciousness, embarrassment, and the influence of skin lesions on clothing choices had the highest scores, indicating a significant effect on social perception. CONCLUSION:  NF1 has a profound impact on a patient's quality of life, as evidenced by the high DLQI scores in our patient cohort. The early identification and management of such patients can help prevent further deterioration of their quality of life.

Role of the Skin Prick Test in Urticaria Patients.

Background Urticaria, a vascular reaction of the skin, is marked by the transient appearance of erythematous papules or plaques (wheals) of varying sizes that are blanchable and associated with severe pruritus which lasts from a few hours to days. The etiological factors for urticaria include food, drugs, bacterial foci, pollen, fungi, dust, worms, physical stimuli, stress, anxiety, insect stings, etc. Skin prick tests (SPTs) represent the cheapest and most effective method to diagnose immunoglobulin E-mediated type 1 allergic reactions such as urticaria. A history suggestive of clinical sensitivity supported by a positive test strongly implicates the allergen in the disease process. In this study, we aimed to detect the common allergens and correlate the findings of SPTs with various epidemiological characteristics of urticaria patients. Methodology A total of 100 patients with urticaria were included in this study. After receiving written and informed consent from patients, SPTs using a battery of 45 allergens were performed. Results In our study, SPT positivity was seen in 88 (88%) patients. The highest sensitization was noted toward Dermatophagoides pteronyssinus (house dust mite) (30%), followed by D. farinae, Cynodon dactylon, and peanuts (each comprising 24%), and Ailanthus excelsa (20%). Conclusions Finding the causative allergen in urticaria is often a difficult and long-drawn process, both for the physician and the patient. Our study identified an allergen in 88% of patients with urticaria, thereby showing that the SPT is a cost-effective, easy, and reliable tool for diagnosing and guiding treatments in urticaria patients.

Using the MCRISP Network for Surveillance of Pediatric Exanthema in Child Care Centers.

BACKGROUND: Systematic monitoring of exanthema is largely absent from public health surveillance despite emerging diseases and threats of bioterrorism. Michigan Child Care Related Infections Surveillance Program (MCRISP) is the first online program in child care centers to report pediatric exanthema. METHODS: MCRISP aggregated daily counts of children sick, absent, or reported ill by parents. We extracted all MCRISP exanthema cases from October 1, 2014 through June 30, 2019. Cases were assessed with descriptive statistics and counts were used to construct epidemic curves. RESULTS: 360 exanthema cases were reported from 12,233 illnesses over 4.5 seasons. Children ages 13-35 months had the highest rash occurrence (45%, n = 162), followed by 36-59 months (41.7%, n = 150), 0-12 months (12.5%, n = 45), and kindergarten (0.8%, n = 3). Centers reported rashes of hand-foot-mouth disease (50%, n = 180), nonspecific rash without fever (15.3%, n = 55), hives (8.1%, n = 29), fever with nonspecific rash (6.9%, n = 25), roseola (3.3%, n = 12), scabies (2.5%, n = 9), scarlet fever (2.5%, n = 9), impetigo (2.2%, n = 8), abscess (1.95, n = 7), viral exanthema without fever (1.7%, n = 6), varicella (1.7%, n = 6), pinworms (0.8%, n = 3), molluscum (0.6%, n = 2), cellulitis (0.6%, n = 2), ringworm (0.6%, n = 2), and shingles (0.2%, n = 1). CONCLUSION: Child care surveillance networks have the potential to act as sentinel public health tools for surveillance of pediatric exanthema outbreaks.

Correlation of Venous Clinical Severity Score With Dermatology Life Quality Index Among Patients With Chronic Venous Insufficiency: A Cross-Sectional Study.

Introduction Chronic venous insufficiency (CVI) is characterized by inadequate functioning of venous valves in the lower limb. CVI is associated with a significant reduction in patient's quality of life (QOL). The severity of CVI was determined by CEAP (clinical, etiological, anatomical, pathophysiological) classification and venous clinical severity score (VCSS). The study is aimed to evaluate and correlate Dermatology Life Quality Index (DLQI) with VCSS, CEAP in patients with CVI. Methods A cross-sectional study of 57 patients with CVI was conducted over a period of 12 months. A sociographic survey, clinical and severity grading using CEAP classification, and VCSS were done for all venous doppler confirmed patients. QOL was evaluated by validated DLQI questionnaires using English and native languages Hindi and Marathi. Results A total of 57 patients with a male to female ratio of 6.1:1 and a mean age of 51.68 years were included in the study. CEAP grading in patients showed 49.12% (C4a), 21.05% (C6), 15.7% (C4b), 7.01% (C3), 3.50% (C2 and C5). Mean VCSS and DLQI were 11.47 and 10.12, respectively; 49.12%, 40.35%, 10.53% of patients had a moderate, very large, and small impact on DLQI respectively, positively correlating to VCSS (P < 0.001). Conclusion From this study, it was observed that VCSS and CEAP positively correlated with DLQI, and the impact increases in proportion with the seriousness of the disease.

Nonselective Beta-Blockers for the Efficacious Healing of Ulcerated Infantile Hemangiomas in Unusual Locations of Two Female Infants.

Infantile hemangiomas (IHs) are the most common vascular soft-tissue tumors of newborns and early childhood with a prevalence rate of approximately 4%-5% in infancy. Most of the IHs regress spontaneously after initial proliferation. Ulceration is one of the most common complications seen in IHs, which heal poorly without treatment. The prevalence of IHs is three times more in females compared to males. The most common location of IH is head and neck with the least being in extremities Oral propranolol and systemic corticosteroids are used as first-line therapy in the treatment. Topical timolol has been used as an alternative to counteract the long-term side effects of the prior modalities. In this study, we are reporting and presenting case reports of two female infants with ulcerated IH who were treated with oral propranolol and topical timolol, respectively, and comparing the efficacy of one over the other. we observed fast and efficacious healing with oral propranolol when used with proper monitoring, as compared to topical timolol, although the latter is more commonly used as it is safer with fewer potential side effects.

Short-Term Effects of Dexamethasone versus Betamethasone on Ultrasonic Measures of Fetal Well-Being: Cohort from a Blinded, Randomized Trial.

INTRODUCTION: Maternal corticosteroid administration for anticipated preterm birth is common; however, the corticosteroid effect on fetal ultrasound and cardiotocograph (CTG) remains contested. This study aimed to evaluate short-term ultrasound and CTG impact of (a) dexamethasone versus betamethasone (b) pooled corticosteroid effect. METHODS: Substudy of blinded randomized trial of dexamethasone versus betamethasone (given <34 weeks). Umbilical artery (UA), middle cerebral artery (MCA), ductus venosus (DV), and uterine artery Doppler, myocardial performance index (MPI), biophysical profile (BPP), and CTG measured pre-corticosteroid then 1, 2, 4, and 7 days post-corticosteroid. RESULTS: Of 47 fetuses (39 singleton; 4 dichorionic, diamniotic twins; and 4 monochorionic, diamniotic twins) in the February 2012-2013 period, 24 received dexamethasone and 23 betamethasone at average gestation 29.8 ± 2.9 weeks. Thirteen pregnancies (30%) had pre-corticosteroid fetal concerns (estimated weight <10th centile and/or abnormal UA/MCA Doppler). Few significant differences were seen post-corticosteroid: DV pulsatility index and right MPI initially decreased 15-20%, and average BPP decreased slightly on days 1-2. There were no major differential effects of dexamethasone versus betamethasone. DISCUSSION/CONCLUSION: No substantive post-corticosteroid effects were seen for most ultrasound/CTG measures in fetuses with heightened preterm birth risk but predominantly normal pre-corticosteroid measures. Clinically, this suggests avoiding overreliance on individual measures for delivery decisions post-corticosteroid; equally, multiple/marked ultrasound changes suggest true pathology and not corticosteroid effect.

A brief review on potential application of mesenchymal stem cell and secretome in combating mortality and morbidity in COVID-19 patients.

Coronavirus disease 2019 (COVID-19) caused by novel Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV2), is typically associated with severe respiratory distress and has claimed more than 525,000 lives already. The most fearful aspect is the unavailability of any concrete guidelines and treatment or protective strategies for reducing mortality or morbidity caused by this virus. Repurposing of drugs, antivirals, convalescent plasma and neutralizing antibodies are being considered for treatment but are still questionable in lieu of the conflicting data, study design and induction of secondary infections. Stem cell therapy has seen substantial advancements over the past decade for the treatment of various diseases including pulmonary disorders with severe complications similar to COVID-19. Recently, mesenchymal stem cells (MSCs) have received particular attention as a potential therapeutic modality for SARS-CoV2 infection due to their ability to inhibit cytokine storm, a hallmark of severe COVID-19. MSCs secretion of trophic factors and extracellular vesicles mediated intercellular signaling are considered as principal contributing factors for tissue recovery. Although, recent preliminary studies have established the safety and efficacy of these cells without any severe secondary complications in the treatment of SARS-CoV2 infection, the rational use of MSCs on a large scale would still require additional relevant clinical investigations and validation of postulated mechanisms of these cells. This review presents the current clinical findings and update on the potential use of stem cell therapy and its secretome in combating the symptoms associated with COVID-19.

Epigenetic and transcriptional regulation of osteoclastogenesis in the pathogenesis of skeletal diseases: A systematic review.

OBJECTIVES: To identify epigenetic and transcriptional factors controlling osteoclastogenesis (OCG), that have been shown to play a role in the pathogenesis of skeletal diseases. METHODS: A systematic review was conducted in accordance with the PRISMA guidelines. The PubMed and EMBASE databases were searched up to 30th April 2020; references of included articles and pertinent review articles were also screened to identify eligible studies. Studies were included if they described epigenetic and/or transcriptional regulation of OCG in a specific skeletal disorder, and quantified alterations in OCG by any well-described experimental method. Risk of bias was assessed by a previously described modification of the CAMARADES tool. RESULTS: The combined searches yielded 2265 records. Out of these, 24 studies investigating 12 different skeletal disorders were included in the review. Osteoporosis, followed by osteopetrosis, was the most commonly evaluated disorder. A total of 22 different epigenetic and transcriptional regulators of OCG were identified; key epigenetic regulators included DNA methylation, histone methylation, histone acetylation, miRNAs and lncRNAs. In majority of the disorders, dysregulated OCG was noted to occur at the stage of formation of committed osteoclast from preosteoclast. Dysregulation the stage of formation of the preosteoclast from late monocyte was noted in rheumatoid arthritis and fracture, whereas dysregulation at stage of formation of late monocyte from early monocyte was noted in osteopetrosis and spondyloarthritis. Quality assessment revealed a high risk of bias in domains pertaining to randomization, allocation concealment, blinding of outcome assessors and determination of sample size. CONCLUSIONS: A variety of epigenetic and transcriptional factors can result in dysregulated osteoclastogenesis in different skeletal disorders. Dysregulation can occur at any stage; however, the formation of committed osteoclasts from preosteoclasts is the most common target. Although the published literature on this subject seems promising, the overall strength of evidence is limited by the small number of studies evaluating individual skeletal disorders, and also by deficiencies in key aspects of study design.

Use of the Foetal Myocardial Performance Index in monochorionic, diamniotic twin pregnancy: a prospective cohort and nested case-control study.

AIMS: Assess clinical utility of the foetal Myocardial Performance Index (MPI) in evaluation and management of monochorionic, diamniotic twin (MCDA) pregnancies. METHODS: Prospective cohort of (a) initially uncomplicated MCDA (b) Complicated MCDA, including twin-twin transfusion syndrome (TTTS), selective intrauterine growth restriction (sIUGR), and liquor and/or growth discordance (L/GD) not meeting TTTS or sIUGR criteria. TTTS and sIUGR were case-control matched. Routine Dopplers and MPI were taken and correlated to diagnosis and final outcome. RESULTS: Twenty-six always uncomplicated pairs, 51 always complicated pairs, and seven uncomplicated to pathological pairs were included. TTTS recipient (n = 25) left and right MPI and intertwin difference (ITD) were significantly elevated, however, were already elevated in Stage I (n = 10), and did not predict progression or pregnancy outcome. sIUGR MPI (n = 11) did not differ significantly from control. Of 15-L/GD pairs, two that progressed to TTTS had significantly higher left and right MPI values in the future recipient (0.61 and 0.72) versus future sIUGR larger twins (0.48 and 0.51) or stable L/GD (0.47 and 0.52): p < .01 for all comparisons. CONCLUSIONS: In this cohort, MPI did not add substantial diagnostic/prognostic information to current routine evaluation in established TTTS or sIUGR though potentially differentiated L/GD cases progressing to TTTS.

Association Between the Cilioretinal Artery and Choroidal Neovascularization in Age-Related Macular Degeneration: A Secondary Analysis From the Age-Related Eye Disease Study.

Importance: A hemodynamic role in the pathogenesis of age-related macular degeneration (AMD) has been proposed, but to our knowledge, an association between retinal vasculature and late AMD has not been investigated. Objective: To determine whether the presence and location of a cilioretinal artery may be associated with the risk of late AMD in the Age-Related Eye Disease Study (AREDS). Design, Setting, and Participants: Retrospective analysis of prospective, randomized clinical trial data from 3647 AREDS participants. Fundus photographs of AREDS participants were reviewed by 2 masked graders for the presence or absence of a cilioretinal artery and whether any branch extended within 500 µm of the central macula. Multivariate regressions were used to determine the association of the cilioretinal artery and vessel location, adjusted for age, sex, and smoking status, with the prevalence of choroidal neovascularization (CNV) or central geographic atrophy (CGA) and AMD severity score for eyes at randomization and progression at 5 years. Main Outcomes and Measures: Association of cilioretinal artery with prevalence and 5-year incidence of CNV or CGA. Results: Among AREDS participants analyzed, mean (SD) age was 69.0 (5.0) years, with 56.3% female, 46.6% former smokers, and 6.9% current smokers. A total of 26.9% of patients had a cilioretinal artery in 1 eye, and 8.4% had the vessel bilaterally. At randomization, eyes with a cilioretinal artery had a lower prevalence of CNV (5.0% vs 7.6%; OR, 0.66; 95% CI, 0.51-0.85; P = .001) but no difference in CGA (1.1% vs 0.8%; OR, 1.33; 95% CI, 0.76-2.32; P = .31). In eyes without late AMD, those with a cilioretinal artery also had a lower mean (SD) AMD severity score (3.00 [2.35] vs 3.19 [2.40]; P = .02). At 5 years, eyes at risk with a cilioretinal artery had lower rates of progression to CNV (4.1% vs 5.5%; OR, 0.75; 95% CI, 0.56-1.00; P = .05) but no difference in developing CGA (2.2% vs 2.7%; OR, 0.83; 95% CI, 0.56-1.23; P = .35) or change in AMD severity score (0.65 [1.55] vs 0.73 [1.70]; P = .11). In patients with a unilateral cilioretinal artery, eyes with the vessel showed a lower prevalence of CNV than fellow eyes (4.7% vs 7.2%; P = .01). Conclusions and Relevance: The presence of a cilioretinal artery is associated with a lower risk of developing CNV, but not CGA, suggesting a possible retinal hemodynamic contribution to the pathogenesis of neovascular AMD. Trial Registration: ClinicalTrials.gov Identifier: NCT00000145.

Deceptive nasal NK/T-cell lymphoma.

Nasal NK/T cell lymphoma is rare and it easily masquerades as chronic rhinosinusitis. It has a very poor prognosis and hence early diagnosis, although difficult, is necessary for better outcome. We present a case of a 30-year-old man who presented with nasal obstruction, facial oedema and crusts. High-resolution computed tomography found soft tissue in all sinuses and the nasal cavity. Endoscopic biopsy revealed necrotic and inflammatory tissue with fungi on culture. A diagnosis of fungal rhinosinusitis was made but the patient did not respond to antifungal drugs. A histopathology review with immunohistochemistry suggested nasal NK/T cell lymphoma. The patient was started on chemotherapy but died within 1 week.

Novel spatial-temporal image correlation derived indices of tissue vascular impedance: A variability study.

OBJECTIVES: 4D (3D + time) indices of tissue impedance using power Doppler (PD) ultrasound (US) can be measured with spatial-temporal image correlation (STIC) imaging. We wished to evaluate their repeatability and their influence under changes to US machine settings and regional differences within the placenta. METHODS: A total of 46 healthy women were recruited at 20-34 weeks of gestation. A total of 9940 3D frames from 644 4D data sets were analysed providing both 3D and 4D indices of vascularity. 4D vs. 3D indices were compared with different machine settings, across the cardiac cycle and in the different placenta regions to assess regional variability. RESULTS: 3D and 4D indices significantly decreased as wall motion filter (WMF) was increased (P < 0.001). Repeatability decreased as WMF increased (ICC; low1 = 0.80; high1 = 0.60). Indices were significantly lower at the maternal aspect (P = 0.002-0.009) of the placenta and showed less repeatability (ICC; 0.42-0.79) than the fetal aspect (ICC 0.49-0.88). 4D repeatability was good in the central region (ICC 0.80-0.81) but poor in the periphery (ICC 0.45-0.59), while 3D indices were good and comparable between regions (ICC; 0.80 central; 0.81 peripheral). CONCLUSIONS: This study supports the future use of WMF 'low1' and PD to generate more reliable 4D indices values. For 3D indices, HD Flow may improve Doppler signal sensitivity. Regarding placental regional variability, the fetal plate and the central region demonstrated more repeatable 4D indices. 4D PD indices have potential to overcome the limitations of VOCAL™ indices and provide an internally standardised measure of localised impedance in vascular beds.

Simultaneous occurrence of Hodgkin's disease and tubercular lymphadenitis in the same cervical lymph node: a rare presentation.

Concomitant presentation of tuberculosis (TB) and lymphoma is a rare entity. A primary malignancy such as Hodgkin's disease (HD) may cause suppression of the cell-mediated immunity, which predisposes to a concomitant TB infection. We report a case of an 18-year-old man, who presented with fever and was found to have pallor, generalised lymphadenopathy, hepatosplenomegaly, ascites and pedal oedema. Ultrasound of the abdomen revealed enlarged lymph nodes in the para-aortic and peripancreatic region. On chest contrast-enhanced CT, calcified mediastinal lymph nodes were seen. A surgical biopsy of a cervical lymph node was performed, which revealed caseous necrosis surrounded by epithelioid cells along with diffuse nodal architectural effacement by large atypical lymphoid cells. Numerous Reed Sternberg cells were also seen. Immunohistochemistry confirmed diagnosis of Hodgkin's lymphoma. The same lymph node came out to be positive for mycobacterium TB on polymerised chain reaction. The patient was given antitubercular therapy concomitantly with chemotherapy for HD, and improved with treatment.

The (Pulsed-Wave) Doppler Fetal Myocardial Performance Index: Technical Challenges, Clinical Applications and Future Research.

Functional cardiovascular assessment is becoming an increasingly important tool in the study of fetal pathology. The myocardial performance index (MPI) is a parameter measuring global myocardial function. Since its introduction, several studies have proposed methods to improve its reproducibility and have constructed normative reference ranges. Fetal heart evaluation using the MPI is technically challenging, requiring specific training and expertise, and a consensus has yet to be reached on the method of delineating the time periods used to calculate the index. Despite these limitations, it has been shown to be a useful and highly sensitive parameter of dysfunction in a number of fetal pathologies. Further research is warranted into the effect of pathology on MPI, parameters of unilateral cardiac strain that utilise MPI, and automation of the MPI to encourage incorporation of the MPI as a useful tool in clinical practice.

Is There a Measurable Difference between the Left and Right Modified Myocardial Performance Indices, and Does This Change to Reflect Unilateral Myocardial Dysfunction in Pathology?

INTRODUCTION: Fetal cardiac dysfunction may manifest itself unilaterally as right and left ventricles differing in design, function and load, measurable as differing in myocardial performance indices (MPIs). We wished to define this difference ('delta-MPI' or DMPI), present its normal range and pilot its use in pathological pregnancy. MATERIAL AND METHODS: Prospective cross-sectional study of 324 normal singleton fetuses (16-38 weeks of gestation). Left and right modified MPI (LMPI and RMPI) were performed during a single examination using the 'peak' valve click technique. Thirty-seven pathological singleton and monochorionic diamniotic twin pregnancies were compared as pilot data. RESULTS: Modified MPIs (mean ± SD) were 0.45 ± 0.06 (LMPI) and 0.47 ± 0.09 (RMPI), being similar at 18 weeks' gestation with DMPI increasing slightly throughout pregnancy (0.02 ± 0.08). Both singleton intrauterine growth restriction (IUGR) and recipient twin-twin transfusion syndrome (TTTS) showed significantly elevated RMPI, LMPI and DMPI, most pronounced for DMPI (450 and 500% increase, respectively; p < 0.01). DMPI acquisition rates were 83.3% normal and 87.0% pathological. DISCUSSION: We demonstrate for the first time differing intrafetal LMPI and RMPI in a large gestational cohort, with this difference increasing with gestational age. Pilot data confirm the potential for DMPI as a tool to assess unilateral myocardial function in singleton IUGR and recipient twins in TTTS, and further studies are under way to evaluate its clinical utility.

Selection of the sub-noise gain level for acquisition of VOCAL data sets: a reliability study.

This study was aimed at assessing the intra-observer and inter-observer repeatability of selecting the sub-noise gain (SNG) level when acquiring placental volumes with 3-D power Doppler for analysis using virtual organ computer-aided analysis (VOCAL). Sixty women with uncomplicated singleton pregnancies between 20 and 38 wk of gestation were recruited. Two women were excluded for flash artifact noted during image analysis. Two blinded observers independently adjusted gain to their perceived SNG level before acquiring a static 3-D volume of the placenta at the cord insertion; observers alternated after each acquisition until each had acquired two volumes. A single observer operated the probe at all times. During offline analysis, SNG levels were recorded and VOCAL indices were calculated. SNG exhibited excellent intra-observer and inter-observer reliability. Intra-observer intra-class correlation coefficients (95% confidence intervals) were 0.98 (0.97-0.99) and 0.98 (0.98-0.99) for observers 1 and 2, respectively. The inter-observer intra-class correlation coefficient was 0.96 (0.93-0.98). Despite its perceived inherent subjectivity, the excellent intra-class correlation coefficients obtained in this study support SNG as a promising tool for future research using 3-D power Doppler.