Bleeding risk assessment in immune thrombocytopenia.

The bleeding risk in immune thrombocytopenia (ITP) is related not only to low platelet count but also to the presence of platelet dysfunction. However, diagnosing a concomitant platelet dysfunction is challenging as most of the available platelet function assays (PFAs) require a platelet count of greater than 100,000/µL. Sonoclot coagulation and platelet function analyzer works on the principle of viscoelastometry, and results remain unaffected by the platelet counts. To assess the platelet function in adult acute ITP patients with the help of sonoclot coagulation and platelet function analyzer and correlate it with the risk of bleeding. Newly diagnosed acute ITP patients with a platelet count less than 20,000/µL were divided into two groups based on WHO bleeding grade: ITP non-bleeder (ITP-NB) group (WHO bleeding grade ≤1) and ITP bleeder (ITP-B) group (WHO bleeding grade ≥2). Platelet function was assessed by sonoclot in both groups. The patients without significant bleeding (ITP-NB) were followed up monthly for six months with the assessment of platelet function during each contact. Eighty patients (30 ITP-B and 50 ITP-NB) were prospectively included in this study. The median age of patients in the two groups was 37 years and 30 years, respectively. The female-to-male ratio was 4:1 and 1:1 in ITP-B and ITP-NB groups. The median platelet count in ITP-B and ITP-NB was 12000/µL (range 1000-19000/µL) and 8000/µL (range 1000-19000/µL), respectively. Mean platelet functions by sonoclot in both groups were lower than the normal cut-off (>1.6). However, the mean platelet function in the ITP-B group (0.2 + 0.17) was significantly lower than the ITP-NB group (1.2 ± 0.52) (p = 0.01). During the follow-up period of 6 months, patients in ITP-NB with a normal platelet function (>1.6) on sonoclot had lesser episodes (one episode) of clinically significant bleeding than patients with a low platelet function (4 episodes). Patients with acute severe thrombocytopenia and bleeding phenotype have a greater abnormality on platelet function by sonoclot than patients with non-bleeding phenotype. This information may help in taking therapeutic decisions in patients with acute ITP.

Simple bedside tests of muscle strength and function correlate with computed tomography-skeletal muscle index for assessment of sarcopenia in cirrhosis.

BACKGROUND: Sarcopenia assessment can be done by skeletal muscle index (SMI) or bedside tests such as handgrip strength (HGS) and gait speed (GS). GOALS: This study evaluated the correlations of HGS and GS with SMI, health-related quality of life (HRQOL) and cognition and assessed them as predictors of mortality. STUDY: As many as 116 outpatients with cirrhosis were included in this prospective cohort study. Assessment for sarcopenia was done by SMI, HGS and GS. HRQOL was assessed using the chronic liver disease questionnaire (CLDQ) and fatigue severity scale (FSS). Cognition was assessed by mini-mental state examination (MMSE). Correlations of HGS and GS with SMI, HRQOL and cognition were analyzed. Area under the curve (AUCs) were calculated to compare them as predictors of mortality. RESULTS: Alcoholic liver disease (47.4%) was the commonest etiology of cirrhosis followed by hepatitis C (12.9%). Sarcopenia was diagnosed in 64 (55.2%) patients. A strong correlation was seen between SMI and HGS (ρ = 0.78) and GS (ρ = 0.65). AUCs of GS (0.91 (95% confidence interval [CI], 0.85-0.96) was maximum, followed by HGS (95% CI, 0.86 [0.78-0.93] and SMI [95% CI, 0.8 0.71-0.88]) in predicting mortality (p > 0.05). CLDQ (3.2 vs. 5.6, p < 0.01) and MMSE scores (24.3 vs. 26.3, p < 0.01) were lower, whereas FSS score (5.7 vs. 3.1, p < 0.01) was higher in patients with sarcopenia. CLDQ (ρ = 0.83) and MMSE (ρ = 0.73) showed the strongest correlation with HGS, whereas FSS correlated well (ρ = 0.77) with GS. CONCLUSIONS: Bedside tests of muscle strength and function, including HGS and GS, correlate strongly with SMI for sarcopenia assessment and prediction of mortality in patients with cirrhosis.

AARC score determines outcomes in patients with alcohol-associated hepatitis: a multinational study.

BACKGROUND AND AIM: Acute-on-chronic liver failure (ACLF) is a severe form of alcoholic hepatitis (SAH). We aimed to study the natural course, response to corticosteroids (CS), and the role of the Asian Pacific Association for the Study of Liver (APASL) research consortium (AARC) score in determining clinical outcomes in AH patients. METHODS: Prospectively collected data from the AARC database were analyzed. RESULTS: Of the 1249 AH patients, (aged 43.8 ± 10.6 years, 96.9% male, AARC score 9.2 ± 1.9), 38.8% died on a 90 day follow-up. Of these, 150 (12.0%) had mild-moderate AH (MAH), 65 (5.2%) had SAH and 1034 (82.8%) had ACLF. Two hundred and eleven (16.9%) patients received CS, of which 101 (47.87%) were steroid responders by day 7 of Lille's model, which was associated with improved survival [Hazard ratio (HR) 0.15, 95% CI 0.12-0.19]. AARC-ACLF grade 3 [OR 0.28, 0.14-0.55] was an independent predictor of steroid non-response and mortality [HR 3.29, 2.63-4.11]. Complications increased with degree of liver failure [AARC grade III vs. II vs I], bacterial infections [48.6% vs. 37% vs. 34.7%; p < 0.001); extrahepatic organ failure [66.9% vs. 41.8% vs. 35.4%; p < 0.001] respectively. The AARC score better discriminated 90-day mortality. Harrell's C-index was 0.72 compared to other scores. CONCLUSION: Nearly 4 of 5 patients with AH present with ACLF. Such patients have a higher risk of infections, organ failures, lower response to CS, and higher mortality. Patients with AH and ACLF with AARC grade 3 should be considered for an early liver transplant.

Is mucormycosis the end? A comprehensive management of orbit in COVID associated rhino-orbital-cerebral mucormycosis: preserving the salvageable.

BACKGROUND: Rhino-orbital-cerebral mucor mycosis (ROCM) is a relatively rare opportunistic infection caused by the Mucorales species. While ROCM suggests involvement of the paranasal sinuses, orbit and brain ROM (rhino-orbital-Mucormycosis) stands for the fungal invasion in sinuses and orbit sans cerebral involvement. In India with the outbreak of the second COVID wave and the delta variant of the virus, there has been a steep increase in this opportunistic fulminant fungal infection, named COVID-associated Mucor mycosis (CAM). The most critical question in orbital management is when to go ahead with an exenteration. Our study aims to design a pertinent minimal invasive surgical protocol for surgeons to manage such cases based on our surgical experience and mitigate the need for exenteration and save the eyes wherever possible. METHODS: The study is a retrospective analysis of patients of ROM with and without brain involvement, who underwent minimal surgical management between March 2021 to March 2022 along with their follow-up. RESULTS: There were 184 eyes of 148 patients diagnosed with CAM. The mean age was 51.7 years with a male predominance of 103 (70%). All patients developed ROM following the COVID-19 infection and the duration between diagnosis of COVID-19 and ROM was 36 ± 23 days. 18 cases (12%) were bilateral. 76 eyes (41%) had no vision at the presentation. Imaging revealed paranasal sinus involvement (100%), orbital apex involvement (61%), cavernous sinus involvement (53%), and central nervous system (CNS) involvement (47%). All the patients (100%) were treated with systemic Liposomal amphotericin-B and sinus debridement. Endoscopic debridement of the orbital disease was performed in 45 (30.4%) cases, 15(8.1%) eyes underwent exenteration and were later rehabilitated with a customized ocular prosthesis, 103 (56%) eyes underwent transcutaneous retrobulbar amphotericin-B. At a mean follow-up of 13.1 months; the complete resolution was seen in 25 (17%) cases, the residual stable lesion was seen in 77(52%) of the cases and new lesions were developed in 13(9%) of the cases. Mortality was seen in 33 (22%) patients and all of them had CNS involvement. CONCLUSIONS: Systemic and protocol-based management can save the life and salvage the eyes.

Whole brain atlas-based diffusion kurtosis imaging parameters for evaluation of minimal hepatic encephalopathy.

BACKGROUND AND PURPOSES: Minimal hepatic encephalopathy (MHE) has no recognizable clinical symptoms, but patients have cognitive and psychomotor deficits. Hyperammonemia along with neuroinflammation lead to microstructural changes in cerebral parenchyma. Changes at conventional imaging are detected usually at the overt clinical stage, but microstructural alterations by advanced magnetic resonance imaging techniques can be detected at an early stage. MATERIALS AND METHODS: Whole brain diffusion kurtosis imaging (DKI) data acquired at 3T was analyzed to investigate microstructural parenchymal changes in 15 patients with MHE and compared with 15 age- and sex-matched controls. DKI parametric maps, namely kurtosis fractional anisotropy (kFA), mean kurtosis (MK), axial kurtosis (AK) and radial kurtosis (RK), were evaluated at 64 white matter (WM) and gray matter (GM) regions of interest (ROIs) in the whole brain and correlated with the psychometric hepatic encephalopathy score (PHES). RESULTS: The MHE group showed a decrease in kFA and AK across the whole brain, whereas MK and RK decreased in WM ROIs but increased in several cortical and deep GM ROIs. These alterations were consistent with brain regions involved in cognitive function. Significant moderate to strong correlations (-0.52 to -0.66; 0.56) between RK, MK and kFA kurtosis metrics and PHES were observed. CONCLUSION: DKI parameters show extensive microstructural brain abnormalities in MHE with minor correlation between the severity of tissue damage and psychometric scores.

Liver transplantation and COVID-19 (Coronavirus) infection: guidelines of the liver transplant Society of India (LTSI).

The Liver Transplant Society of India (LTSI) has come up with guidelines for transplant centres across the country to deal with liver transplantation during this evolving pandemic of COVID-19 infection. The guidelines are applicable to both deceased donor as well as living donor liver transplants. In view of the rapidly changing situation of COVID-19 infection in India and worldwide, these guidelines will need to be updated according to the emerging data.

Correction to: Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update.

The article Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update, written by [Shiv Sarin], was originally published electronically on the publisher's internet portal (currently SpringerLink) on June 06, 2019 without open access.

Changes in salivary output after induction at high-altitude areas and its effects on dental caries among Indian Army troops.

BACKGROUND: This study was aimed to evaluate the changes in salivary output and its effect on dental caries among Indian troops after 6 months of stay at high-altitude area (HAA). METHODS: All troops undergo mandatory dental checkup during acclimatization phase before deployment at HAA. Two thousand troops who fulfilled inclusion and exclusion criteria were selected, and consent for the study was obtained. Stimulated and unstimulated salivary samples were collected, the decayed, missing, and filled teeth (DMFT) index was evaluated, and required dental treatment was completed. The same salivary samples were collected after 6 months (on deinduction) to evaluate the salivary output. The DMFT index was re-evaluated to check the initiation of caries. RESULTS: The mean values of unstimulated and stimulated saliva at the initial visit were 4.105 and 17.03 gm, respectively, whereas the mean values of unstimulated and stimulated saliva after 180 days were 3.034 and 15.831 gm, respectively. Salivary flow was found to be significantly decreased after 6 months both in unstimulated and stimulated saliva. The mean DMFT at the time of induction of the study was 6.18 ± 3.03, and on deinduction, it was 7.22 ± 3.45 with p < 0.001, which was highly statistically significant. CONCLUSION: A decrease in body fluids and changed sympathetic and parasympathetic at HAA lead to decreased salivary secretions. Low water intake, high carbohydrate solid diet, negligible supply of fresh food, difficulty in maintenance of oral hygiene, and overall stress due to loneliness are all contributory factors for an increase in dental caries. It clearly demonstrates that prolonged stay at HAA affects salivary volume outflow, both stimulated and unstimulated, which has a corresponding effect on new caries.

Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update.

The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set up in 2004 on acute-on-chronic liver failure (ACLF) was published in 2009. With international groups volunteering to join, the "APASL ACLF Research Consortium (AARC)" was formed in 2012, which continued to collect prospective ACLF patient data. Based on the prospective data analysis of nearly 1400 patients, the AARC consensus was published in 2014. In the past nearly four-and-a-half years, the AARC database has been enriched to about 5200 cases by major hepatology centers across Asia. The data published during the interim period were carefully analyzed and areas of contention and new developments in the field of ACLF were prioritized in a systematic manner. The AARC database was also approached for answering some of the issues where published data were limited, such as liver failure grading, its impact on the 'Golden Therapeutic Window', extrahepatic organ dysfunction and failure, development of sepsis, distinctive features of acute decompensation from ACLF and pediatric ACLF and the issues were analyzed. These initiatives concluded in a two-day meeting in October 2018 at New Delhi with finalization of the new AARC consensus. Only those statements, which were based on evidence using the Grade System and were unanimously recommended, were accepted. Finalized statements were again circulated to all the experts and subsequently presented at the AARC investigators meeting at the AASLD in November 2018. The suggestions from the experts were used to revise and finalize the consensus. After detailed deliberations and data analysis, the original definition of ACLF was found to withstand the test of time and be able to identify a homogenous group of patients presenting with liver failure. New management options including the algorithms for the management of coagulation disorders, renal replacement therapy, sepsis, variceal bleed, antivirals and criteria for liver transplantation for ACLF patients were proposed. The final consensus statements along with the relevant background information and areas requiring future studies are presented here.

A clinico radiographic study of immediate loading implants in rehabilitation of mandibular ridges.

BACKGROUND: Numerous studies regarding the immediate loading of splinted implants retaining/supporting mandibular dentures have reported promising results, but studies comparing splinted and unsplinted attachments for supporting overdentures with immediate loading are limited. Scientific literature is sparse comparing various attachment systems and patient satisfaction in response to immediately loaded implant supported overdentures. METHODS: A total of 30 completely edentulous patients male or female, in the age group of 54-78 years (mean age 65 years), wearing conventional complete dentures were selected and randomly divided in to two groups. A total of 60 implants were placed in the interforaminal area of the mental symphysis (two implants per patients) in 30 patients. Two types of attachment systems namely Ball for group-A and Bar for group-B were used and immediate loading done. Implants were evaluated clinically and radiographically at baseline, 1 month, 3 months, 6 months and 9 months. All clinical and radiographic parameters were subjected to statistical analysis. RESULT: The implant survival rate for group-A (ball attachment) was 93.3% and implant survival rate for group-B (bar attachment) was 93.3%. The overall implant survival rate was not dependent on the attachment system. There was no significant difference in the crestal bone loss in mesial, and distal side in implants with respect to ball and bar attachment for different period of observation (F = 0.25; P = 0.910; F = 0.07; P = 0.992 respectively). CONCLUSION: Overdenture supported by two implants should be the minimum gold standard in the rehabilitation of completely edentulous patients.

Evaluation of flexural strength of resin interim restorations impregnated with various types of silane treated and untreated glass fibres.

BACKGROUND: Flexural strength is an important mechanical property that determines the long-term prognosis of interim restorations. Studies are lacking regarding the effect of silanation of the various types of glass fibre impregnation on the flexural strength of resin interim restorations. METHODS: A customized metal die was milled to simulate the prepared abutments of a three-unit fixed dental prosthesis. A total of seventy five samples of interim fixed dental prostheses were prepared using autopolymerizing tooth colour acrylic resin. Unidirectional and woven forms of glass fibres (Stick and Stick Net), which were silane treated and untreated were used to reinforce the resin matrix. Fifteen samples were prepared for each group along with unreinforced group serving as control. The flexural strength was evaluated with universal testing machine. RESULTS: The means and standard deviations of flexural strength for different groups were 13.90 ± 2.96 (control), 61.58 ± 5.26 (unidirectional fibres), 30.89 ± 3.60 (woven fibres), 112.05 ± 5.51 (silane treated unidirectional fibres) and 73.85 ± 4.10 (silane treated woven fibres) respectively. The mean flexural strength of silane treated unidirectional fibres (112.05 MPa) was highest and statistically highly significant (P < 0.0001) compared to all other groups. CONCLUSIONS: Within the limitations of the current study, flexural strength of the reinforced PMMA interim fixed dental prosthesis was significantly higher (P < 0.0001) when compared to the unreinforced PMMA interim fixed dental prosthesis. The use of silane treated unidirectional glass fibres is an effective method of reinforcing interim fixed restorations made of PMMA resins.

Evaluation of the effect of surface preparation using phosphoric acid and luting cement on the flexural strength of porcelain laminate veneering material.

BACKGROUND: Conventionally HF acid has been used for etching ceramic veneer restorations before their cementation. Studies are lacking regarding the effectiveness of phosphoric acid as a substitute for HF acid for etching the ceramic veneers. The purpose of this study was to evaluate the effectiveness of surface preparation of porcelain laminate veneers using phosphoric acid, as compared to HF acid etching in providing the necessary surface roughness conducive to development of an effective bond between the ceramic laminate and the resin luting cement. METHODS: 210 porcelain discs of 15 mm diameter and 0.9 mm thickness were prepared. These study samples were divided into seven groups of thirty samples each. Surfaces of the first (control) and the second group of samples were not prepared. The surfaces of other five groups were prepared with different surface treatments. Further all the groups of specimens were coated with a layer of resin luting cement. Flexural strength of each specimen was determined using universal testing machine and the results were compared. RESULTS: The combination surface treatment using alumina surface abrasion followed by etching with phosphoric acid provided the highest flexural strength with the mean flexural strength of 101.11 MPa, followed by alumina surface abrasion (95.41 MPa), and phosphoric acid surface etching (81.68 MPa). CONCLUSION: Laminate veneers surface treated using 50 µm alumina abrasion followed by etching with phosphoric acid showed the highest flexural strengths after resin coating compared to other groups.

Intrapulpal thermal changes during direct provisionalization using various autopolymerizing resins: Ex-vivo study.

BACKGROUND: Resin materials used in the fabrication of direct provisional restoration exhibit an exothermic reaction and the extent of damage may also depend on the remaining dentine thickness. An ex-vivo study was envisaged to compare the time related temperature changes in the pulp chamber during the fabrication of fixed partial denture provisional restorations using direct technique. The effect of differently prepared teeth (with varying remaining dentine thickness) on the above mentioned temperature changes were also evaluated. METHODS: Thermal changes were calculated in pulp chamber of three differently prepared tooth having different amount of remaining dentinal thickness (45 samples) and control with no tooth media (15 samples), using three different types of autopolymerizing provisional restorative materials using Cr/Al thermocouple connected to digital thermometer. RESULTS: The data for the mean peak temperature rise was subjected to one way ANOVA analysis for relative comparison among subgroups within each main group and across the main groups. The results showed a statistically significant difference across both the subgroups and the main groups (p < 0.001). Then Turkey HSD test was applied to determine the significance of statistical difference between the means, within the groups. The differences in temperature rise were statistically significant for the three resins (p < 0.001). CONCLUSION: Polymethylmethacrylate (DPI) showed the highest temperature rise value followed by polyethyl methacrylate (Tempron) and Bis-acrylate composite (CoolTemp). The maximum temperature rise was found on molar full veneer preparation followed by molar three quarter preparation and premolar three quarter preparation. Data and results from current study may assist clinicians to select an autopolymerizing provisional restorative resin when employing direct technique of fabricating provisional restorations for a specific tooth preparation which would cause minimal thermal trauma to pulpal tissue.

Dimensional accuracy of two rubber base impression materials as a function of spacer design and techniques in custom trays for fixed partial dentures.

BACKGROUND: A prostheses can't be better than the cast over which it has been fabricated. To make accurate casts, accurate impressions are mandatory. To get an accurate and dimensionally stable impression, various techniques and materials have been advocated. This study compares the most commonly used techniques and materials for dimensional accuracy. Two types of spacers were designed to compare the addition silicon and polyether and their techniques. METHODS: A metal die was used to make the impressions. A total of 60 impressions were made using multiple mix and monophasic techniques for addition silicon and polyether in custom trays. A travelling microscope was used to measure the dimensional accuracy of die stone casts retrieved from impressions. RESULTS: The results were compared using paired t test and SPSS software. The study was highly significant (p < 0.001). The polyether was more accurate than the addition silicon and spacer design I (adapted to the edentulous area) was more accurate than the design II (spacer over the abutments, not adapted to edentulous area). The multiple mix technique was more accurate than the monophasic for addition silicon. CONCLUSION: The combination of multiple mix technique with spacer design I for addition silicon gave the best accurate results.

Comparative study of immediate functional loading and immediate non-functional loading of monocortical implants.

BACKGROUND: Attempts to shorten the overall length of treatment have focused on immediate loading, subsequent to implant placement. Prosthetic rehabilitation immediately after implant placement can be either functional or non-functional in nature. There is paucity of literature on the comparative evaluation of immediate functional and immediate non-functional loading of implants. This in-vivo study was undertaken to comparatively evaluate Immediate Functional Loading and Immediate Non-Functional Loading of monocortical implants with a follow-up period of 18 months. METHODS: 50 partially edentulous cases were selected for the study. The cases were divided into two groups. In first group (Group-1), 25 implants were subjected to immediate functional loading. In second group (Group-2), 25 implants were subjected to immediate non-functional loading. The crestal bone loss, clinical stability and degree of osseointegration of these two groups were comparatively evaluated. RESULTS: The crestal bone loss in both groups was within acceptable limits. The implant stability, which is a reflection of the status of bone-to-implant interface, was comparable in both the groups at different time intervals. Although, the ISQ values in Group-2 were slightly higher than those in Group-1, the results were not statistically significant. Radiodensity indicating degree of osseointegration at different time intervals in both groups was also comparable. CONCLUSION: Both the IFL and INFL protocols can be undertaken satisfactorily in rehabilitation using endosseous implants; however, the main factors for success in IFL and INFL are case selection, meticulous treatment planning and the precision of technique.