New-onset movement disorder in the immediate postpartum period.

This case report describes a woman who developed involuntary, uncoordinated movements of her face and limbs following a spontaneous vaginal delivery, complicated by postpartum haemorrhage. Using systematic assessment with multidisciplinary team input, a differential diagnosis was proposed and relevant investigations were undertaken. Atypical eclamptic or generalised seizures were excluded clinically and neuroimaging ruled out an intracranial vascular event such as stroke or venous sinus thrombosis. Local anaesthetic systemic toxicity was managed empirically with intravenous lipid emulsion and intravenous fluids. A diagnosis of drug-induced dyskinesia was made, most likely secondary to ondansetron, with which dystonias and myoclonus have been described. This woman's symptoms were transient and resolved within 2 hours.This case presented a complex differential diagnosis, highlighting the paucity of guidance available. We propose a diagnostic algorithm to aid in the identification of acute involuntary movements in pregnancy and the puerperium.

Short-course Venetoclax With Standard Chemotherapy Is Effective in Early T-cell Precursor Acute Lymphoblastic Leukemia.

BACKGROUND: Early T-cell precursor acute lymphoblastic leukemia (ETP ALL) is a high-risk subgroup of acute lymphoblastic leukemia characterized by unique immune phenotype and disease biology. ETP ALL cells share similarities with hematopoietic stem cells and myeloid progenitor cells. These patients have lower rates of complete remission and overall survival. High BCL2 expression is the main rationale for using venetoclax in ETP ALL. RESULTS: We report the treatment outcomes of 2 patients with ETP ALL who achieved minimal residual disease negative remission with the short course of venetoclax. CONCLUSIONS: Combination therapy of short-course venetoclax with Berlin-Frankfurt-Meunster 95 regimen is an effective regimen for treating patients with ETP ALL.

Innovator Filgrastim versus Generic Filgrastim in Hematopoietic Stem Cell Transplantation Mobilization.

Methods This is a retrospective study. G-CSF was administered in the dose of 10 µg/kg subcutaneous as a single dose for 4 days. On day 5, peripheral blood stem cell (PBSC) apheresis was performed using Haemonetics MCS plus or COBE Spectra apheresis machine through a double-lumen central venous catheter. Primary outcome parameters were the total number of CD34+ HSCs/kg of recipient weight mobilized in peripheral blood and the number of days required for neutrophil and platelets engraftment, respectively. Objective We compared the effectiveness and safety of innovator filgrastim versus generic filgrastim in patients who underwent hematopoietic stem cell transplantation (HSCT). Results A total of 91 stem cell mobilizations was analyzed. There were 58 normal healthy donors for allogeneic HSCT and 33 patients for autologous HSCT. There was no statistically significant difference among groups in terms of total collected CD34+ cells value ( p = 0.609). The mean time to neutrophil engraftment was 13.7 days in the innovator group and 13.2 days in the Grafeel group ( p = 0.518). The mean time to platelet engraftment was 16.2 days in the innovator group and 14.8 days in the generic group ( p = 0.435). The patient who received generic filgrastim had more febrile episodes during the course of transplantation ( p = 0.020). Conclusion Generic filgrastim was found to be comparable to original filgrastim for peripheral blood stem cell mobilization in normal healthy donors for allogeneic HSCT and patients for autologous HSCT.

Quick Response codes for virtual learner evaluation of teaching and attendance monitoring.

Implication Statement Monitoring attendance and obtaining timely learner evaluations for virtual teaching sessions can be challenging. At our Obstetrics and Gynecology webinar programme, we have utilised Quick Response (QR) codes this purpose. Following each session, attendees scan an on-screen QR code which links to an online evaluation form and registers their attendance. Feedback can therefore be obtained quickly, is scalable to large participant numbers and is securely stored in digital format. QR reader applications are widely available and cost-free, which makes this technique accessible for learners. Using QR codes for teaching evaluation is simple and could be adopted across many educational applications. Énoncé des implications de la recherche Contrôler la présence des étudiants aux cours en ligne et obtenir en temps utile leur évaluation des séances d'enseignement virtuelles peut constituer un défi. Dans notre programme de webinaires en obstétrique et gynécologie, nous le faisons à l'aide de codes de réponse rapide (codes QR). Après chaque séance, les participants scannent un code QR qui apparaît sur leur écran; la lecture du code permet de confirmer leur présence et renvoie à un formulaire d'évaluation en ligne. Ce mécanisme rend possible la rétroaction rapide, la participation d'un grand nombre de personnes et la conservation sécuritaire de l'information en format numérique. Les applications de lecture de codes QR sont largement disponibles et gratuites, et donc accessibles aux étudiants. L'utilisation des codes QR pour évaluer les cours est simple et elle peut être intégrée dans de nombreuses applications éducatives.

Effectiveness of convalescent plasma in Indian patients with COVID-19.

BACKGROUND: Convalescent plasma (CP) is being used as a treatment option in hospitalized patients with COVID-19. Till date, there is conflicting evidence on efficacy of CP in reducing COVID-19 related mortality. OBJECTIVE: To evaluate the effect of CP on 28-day mortality reduction in patients with COVID-19. METHODS: We did a multi-centre, retrospective case control observational study from 1st May 2020 to 31st August 2020. A total of 1079 adult patients with moderate and severe COVID-19 requiring oxygen, were reviewed. Of these, 694 patients were admitted to ICU. Out of these, 333 were given CP along with best supportive care and remaining 361 received best supportive care only. RESULTS: In the overall group of 1079 patients, mortality in plasma vs no plasma group was statistically not significant (22.4% vs 18.5%; p = 0.125; OR = 1.27, 95% CI: 0.94--1.72). However, in patients with COVID-19 admitted to ICU, mortality was significantly lower in plasma group (25.5% vs 33.2%; p = 0.026; OR = 0.69, 95%CI: 0.50-0.96). This benefit of reduced mortality was most seen in age group 60 to 74 years (26.7% vs 43.0%; p = 0.004; OR = 0.48, 95% CI: 0.29-0.80), driven mostly by females of this age group (23.1% vs 53.5%; p = 0.013; OR = 0.26, 95% CI: 0.09-0.78). Significant difference in mortality was observed in patients with one comorbidity (22.3% vs 36.5%; p = 0.004; OR = 0.50, 95% CI: 0.31-0.80). Moreover, patients on ventilator had significantly lower mortality in the plasma arm (37.2% vs 49.3%; p = 0.009; OR = 0.61, 95% CI: 0.42-0.89); particularly so for patients on invasive mechanical ventilation (63.9% vs 82.9%; p = 0.014; OR = 0.37, 95% CI: 0.16-0.83). CONCLUSION: The use of CP was associated with reduced mortality in COVID-19 elderly patients admitted in ICU, above 60 years of age, particularly females, those with comorbidities and especially those who required some form of ventilation.

Daratumumab for pure red cell aplasia post ABO incompatible allogeneic hematopoietic stem cell transplant for aplastic anemia.

Pure red cell aplasia is a known complication after ABO incompatible stem cell transplant. Due to rarity of disease, no established treatment guidelines are available for PRCA. Daratumumab is a monoclonal antibody against CD38 expressed by plasma cells. In this report we present our experience of successfully managing a patient of post-transplant PRCA with daratumumab. Our patient had failed multiple lines of therapy prior to receiving daratumumab. Response was seen after the 3rd weekly dose of daratumumab.

Impact of the EPISCISSORS-60 mediolateral episiotomy scissors on obstetric anal sphincter injuries: a 2-year data review in the United Kingdom.

INTRODUCTION AND HYPOTHESIS: This time-series analysis was carried out to determine if the use of the EPISCISSORS-60®, episiotomy scissors specifically designed to achieve a cutting angle of 60°, would continue to sustain obstetric anal sphincter injuries (OASIS) reductions at our hospital 2 years after its introduction. METHODS: We compared data from 2,342 women delivered in 2014 (prior to the introduction of EPISCISSORS-60®) with that of 4,498 women delivered from 2016 to 2017 (after the introduction of EPISCISSORS-60®). RESULTS: There was a reduction of OASIS in all nulliparous vaginal deliveries (NVD; 7.2% vs 5.1% p = 0.05), and a 50% reduction of OASIS (7.5% vs 3.7%) in operative vaginal deliveries (OVD) (p = 0.02). There was a statistically significant association between episiotomies performed with EPISCISSORS-60® and a reduction in OASIS (SVD: 6.9% vs 1.5% p = 0.006; OVD:28.6% vs 2.6% p < 0.0001). Additionally, there was an increase in the use of episiotomies in all nulliparous vaginal deliveries (29% vs 33.7%; p = 0.01). We also found a 78% reduction of OASIS with episiotomies compared with no episiotomies in the 2016-2017 group (6.9% vs 1.5% p = 0.006). CONCLUSIONS: Our results suggest that there might have been a sustained reduction in OASIS rates associated with using EPISCISSORS-60®.

Adequate Engraftment With Lower Hematopoietic Stem Cell Dose.

BACKGROUND: Adequate hematopoietic stem cell dose is required to proceed with autologous stem cell transplantation (ASCT). PATIENTS AND METHODS: We conducted a retrospective analysis of 108 patients with multiple myeloma and lymphoma who underwent ASCT with noncryopreserved stem cells at our center. Data were compared for patients who received stem cell dose < 2 × 106/kg with those who received a higher dose. RESULTS: The median CD34 dose collected in the lesser dose group was 1.76 × 106/kg (1.22 to 1.97 × 106/kg). Mean CD34 dose of the whole group was 4.96 ± 4.2 × 106/kg. Neutrophil engraftment was similar in both groups (12 vs. 11 days) (P = .065). Similarly, platelet engraftment occurred in 12 versus 11 days in both groups (P = .017). Length of hospital stay was similar in both groups. There was no significant difference in the incidence of proven bacterial infections between the 2 groups. There was no transplant-related mortality in lower dose group. CONCLUSION: ASCT can be safely performed with lower hematopoietic stem cell dose in noncryopreserved setting.

Quality improvement can revolutionize tuberculosis care in India: A review.

BACKGROUND/PURPOSE: Access, cost and quality are limiting parameters of any healthcare delivery system. RNTCP (Revised National Tuberculosis Control Program) has largely addressed the access and cost issues, however the quality of care is a major hurdle in TB care today. METHODS: We propose using an evidence based method of quality improvement principles to address many quality issues ranging from delayed turnaround time in testing, to low patient satisfaction, and slow private sector engagement. RESULTS: We propose a 5 step approach to learning and conducting quality improvement at the district level. Step 1: Form a team and define the problem Step 2: Develop baseline data Step 3: Create a process map Step 4: Bring a change through a PDSA Plan-Do-Study-Act cycle Step 5: Prepare run charts. CONCLUSION: We cannot expect a different result by doing the same thing over and over again. This holds particularly true for the TB program in India. A major paradigm shift is necessary if we wish to achieve TB Free within our lifetimes. A shift from quality assurance to quality improvement offers this hope for change and TB elimination.

Complementary therapy and alternative medicine: effects on induction of labour and pregnancy outcome in low risk post-dates women.

BACKGROUND: Complementary therapy and Alternative medicine (CAM) is used worldwide for many ailments and is a popular option amongst pregnant women for general wellbeing and managing symptoms. Many studies investigating the use of CAM in the antenatal and intrapartum period have been conducted however there is a lack of evidence regarding its effects on induction of labour and delivery. We established a post-dates clinic comprising of an antenatal check and CAM for low risk pregnant women to determine the impact of CAM on these outcomes. METHODS: This was a cohort study with convenience sampling. A total of 1044 women were included. 397 received a combination of three CAM techniques (acupressure, reflexology and aromatherapy) and 647 women received standard clinical practice. The primary outcome was rate of induction of labour and secondary outcomes such as rates for epidural, length of labour, oxytocin use for induction or augmentation of labour, mode of delivery, blood loss during delivery, postpartum haemorrhage, significant perineal trauma, shoulder dystocia and admission of the baby to a special care unit were analysed. FINDINGS: CAM did not have an effect on rates of induction of labour in nulliparous or multiparous women attending the post-dates clinic. However, we noted that nulliparous women who received CAM had shorter labours (mean 8.4 vs 10 h, p = 0.0002), less oxytocin augmentation (23% vs 35%, p = 0.0002), lower epidural rates (41% vs 50.5%, p = 0.02) and reduced blood loss regardless of mode of delivery (mean reduction 82ml, p = 0.03; 95%CI = -159 to -5). There were no significant differences in secondary outcomes when CAM was used in multiparous women apart from a 5.3 times increased risk of significant perineal trauma (6% vs 2%, p = 0.004) and those who had their labours induced after CAM had a higher risk of requiring an emergency caesarean section (5% vs 1%, p = 0.012). There was no difference on shoulder dystocia and neonatal admissions rates with CAM. CONCLUSION: There is no reduction in induction of labour rates with the use of CAM. The other effects of CAM on labour and delivery outcomes are varied and potentially only beneficial in a selected group of women. Further research must be carried out before making any clear recommendations on its use.

Paroxysmal Cold Hemoglobinuria in a 4-year-old Child.

Paroxysmal Cold Hemoglobinuria is a rare cause of intravascular hemolysis presenting in children following an acute viral illness. It is usually self-limiting in nature. We present the details of a 4-year-old boy who presented with rapid onset intravascular hemolysis. Donath Landsteiner antibody test was positive and hemolysis resolved within two weeks of onset.