Impact of COVID-19 on Clinical Practices during Lockdown: A pan India Survey of Orthopaedic Surgeons.

INTRODUCTION: The social lockdown measures imposed to contain the COVID-19 pandemic, have had profound effects on the healthcare systems across the world and India has been no exception to it. The study was aimed to evaluate the impact of COVID-19 on orthopaedic practice in India during the lockdown period and assess the preparedness of orthopaedic surgeons for resuming clinical practice after the initial lockdown was lifted. MATERIALS AND METHODS: An online survey of 35 questions was conducted to evaluate impact on (i) general orthopaedic practice (ii) hospital protocols (iii) out-patient practice (iv) surgical practice (v) personal protective equipment (PPE) use and (vi) post-lockdown preparedness. RESULTS: A total number of 588 practising orthopaedic surgeons from India completed the survey. Majority (88.3%) found severe impact (>50%) on trauma surgery and non-trauma surgery with significant reduction in out -patient attendance compared to corresponding time in 2019. There were significant changes made in individual hospital protocols (91.7 %). Appropriate required PPE was available in majority of the hospitals (74.3%). No remodelling or upgrading of the existing operating theatre infrastructure was done by most surgeons (89.5%). CONCLUSION: This pan India survey of orthopaedic surgeons has indicated that COVID-19 has had a profound impact on their outpatient and surgical trauma and non-trauma practice, due to the lockdown and resulted in significant changes to hospital protocols. Preparedness to resume clinical and surgical practice was associated with anxiety in two-thirds of the respondents. Majority of the orthopaedic practitioners felt that they would continue to conduct pre-operative COVID-19 screening and use PPE even after the lockdown is over.

Impact of COVID-19 on Clinical Practices during Lockdown: A pan India Survey of Orthopaedic Surgeons

@#Introduction: The social lockdown measures imposed to contain the COVID-19 pandemic, have had profound effects on the healthcare systems across the world and India has been no exception to it. The study was aimed to evaluate the impact of COVID-19 on orthopaedic practice in India during the lockdown period and assess the preparedness of orthopaedic surgeons for resuming clinical practice after the initial lockdown was lifted. Materials and Methods: An online survey of 35 questions was conducted to evaluate impact on (i) general orthopaedic practice (ii) hospital protocols (iii) out-patient practice (iv) surgical practice (v) personal protective equipment (PPE) use and (vi) post-lockdown preparedness. Results: A total number of 588 practising orthopaedic surgeons from India completed the survey. Majority (88.3%) found severe impact (>50%) on trauma surgery and nontrauma surgery with significant reduction in out -patient attendance compared to corresponding time in 2019. There were significant changes made in individual hospital protocols (91.7 %). Appropriate required PPE was available in majority of the hospitals (74.3%). No remodelling or upgrading of the existing operating theatre infrastructure was done by most surgeons (89.5%). Conclusion: This pan India survey of orthopaedic surgeons has indicated that COVID-19 has had a profound impact on their outpatient and surgical trauma and non-trauma practice, due to the lockdown and resulted in significant changes to hospital protocols. Preparedness to resume clinical and surgical practice was associated with anxiety in two-thirds of the respondents. Majority of the orthopaedic practitioners felt that they would continue to conduct pre-operative COVID-19 screening and use PPE even after the lockdown is over.

Clinical profile and outcomes of De novo posttransplant thrombotic microangiopathy.

Thrombotic microangiopathy (TMA) after kidney transplant is rather uncommon but an important reversible cause of graft loss. This retrospective study of biopsy-proven posttransplant TMA was done to identify the important etiological factors, clinical features, and outcomes of post transplant TMA in a tertiary care referral hospital in northern India. This retrospective study was conducted among all renal transplant recipients who presented with graft dysfunction between 1989 and 2015. All the cases were looked for their etiology, clinical course, treatment modalities, and renal outcomes. The study was conducted in accord with prevailing ethical principles and reviewed by our own institutional review board. Seventeen patients out of 2000 (0.008%) transplants done during the study period had posttransplant TMA, out of which all the patients had de novo TMA, and the median time of presentation after transplantation was four months. Systemic TMA was noted in only four patients. Biopsy revealed associated rejection in five patients and associated calcineurin inhibitor (CNI) toxicity in 12 patients. Patients with TMA due to CNI toxicity were managed with CNI reduction or switching to alternate CNI or mammalian target of rapamycin inhibitors. In addition, antithymocyte globulin and plasma exchange were used in rejection-associated TMA. While four out of 12 patients (33%) in CNI-related TMA developed end-stage renal disease (ESRD), all patients in rejection-associated TMA developed ESRD. The overall one-year graft survival was 47%, whereas five- and 10-year survival was 35%. There was no significant difference in graft survival between localized and systemic TMAs (P = 0.4). Posttransplant TMA should be suspected even if there are no systemic features of hemolysis and early graft biopsy and prompt action is needed. The occurrence of TMA in the setting of rejection is associated with grave prognosis.

Late Posttransplant Lymphoproliferative Disease: Report of a Rare Case and Role of Positron Emission Tomography-computed Tomography.

Posttransplant lymphoproliferative disease (PTLD) is an uncommon complication of immunosuppression after solid organ transplantation. Early PTLD (<1 year after transplantation) is frequently found around the allograft, whereas late PTLD (>1 year after transplantation) does not have such a preference. 18-Fluorodeoxyglucose positron emission tomography-computed tomography (18FDG PET-CT) has clinical significance in the evaluation of PTLD. 18FDG PET-CT scan allows precise anatomic localization of FDG-avid lesions, hence helpful in staging of disease and evaluation of response to therapy. It can better characterize persistent lesions and differentiate residual tumor from fibrosis or necrosis. We present a rare case report of a perigraft PTLD developing 12 years after renal transplantation sparing the graft, in an Epstein-Barr virus-negative patient.

Role of Preoperative Duplex Ultrasonography to Predict Functional Maturation of Wrist Radiocephalic Arteriovenous Fistula: A Study on Indian Population.

Radiocephalic arteriovenous fistula (RCAVF) is the first choice for native arteriovenous fistula (AVF). Preoperative vessel assessment with ultrasonography (USG) has been reported to enhance the outcome of native AVF, but data regarding its predictive value for functional maturation of RCAVF are scanty. We aimed to determine the role of preoperative duplex USG (DUS) for prediction of functional maturity of radiocephalic fistula in the wrist. The data from 173 patients were analyzed prospectively. The estimated duplex variable included size, patency, and continuity of cephalic vein and size, peak systolic velocity, and wall calcifications in radial artery at the wrist. The subjects underwent RCAVF creation and were reviewed 6-8 weeks post procedure for adequacy of maturation. Doppler variables between successful and failed maturation groups were compared. Successful functional fistula maturation was noted in 138 (80.9%) patients. Values of radial artery diameter, cephalic vein diameter, and peak systolic velocity were >2 mm, 2.2 mm, and 32.8 cm/s, respectively, for successful maturation of RCAVF in more than 90% of cases. Vascular calcifications were detected preoperatively in 15 diabetic patients and 9 (60%) of them had fistula failure. Preoperative DUS can provide a good prediction on functional maturation of RCAVF. Vascular calcifications were associated with high risk of maturation failure in diabetics.

Postrenal Transplant Metastatic Colonic Neoplasm: Posttransplant Lymphoproliferative Disorder or Adenocarcinoma?

Transplant recipients are vulnerable to a horde of infections and neoplastic conditions due to immunosuppression. Posttransplant lymphoproliferative disorder (PTLD) is a condition unique to the transplant recipient occurring due to monoclonal lymphocytic proliferation. It may affect any organ system with reportedly highest incidence in the gastrointestinal tract. The incidence of adenocarcinoma of the colon, however, has not been shown to be uniformly higher in transplant recipients. We report here an unusual case of adenocarcinoma of the ascending colon presenting with liver, lymph node and skin metastasis in a transplant recipient, which simulated PTLD both clinically and radiologically. For any gastrointestinal lesion in transplant recipient, the possibility of carcinoma must be considered. However, a high index of suspicion for PTLD facilitates early diagnosis since the treatment of the two conditions is starkly different.

Anconeus pedicle olecranon flip osteotomy: an approach for the fixation of complex intra-articular distal humeral fractures.

In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications.

The fluoride contents of commercially-available soya milks in the UK.

BACKGROUND: In some parts of the world, soya milks are found to be a significant source of fluoride (F). Among western commercial markets, although there has been a sustained increase in soya milk products available for purchase, there are limited data on their F content. OBJECTIVE: To determine the F content of soya milk products available in the UK market including fresh and ultra-high temperature products in addition to sweetened and unsweetened soya milks. MATERIALS AND METHODS: Fifty-two traditional and UK-produced soya milk samples commercially available in northeast England were analysed to determine their F concentration using a modified hexamethyldisiloxane-facilitated diffusion method with a F-ion-selective electrode coupled to a potentiometer. RESULTS: The median F concentration of all products was 0.293 µg/ml ranging from 0.015 µg/ml to 0.964 µg/ml. The median F concentration of ultra-high temperature (UHT) (n = 42) milks was 0.272 µg/ml lower than 0.321 µg/ml obtained for fresh (n = 10) soya milks. Organic soya milks contained less F compared with non-organic for sweetened and unsweetened categories. CONCLUSION: Commercially available soya milks in the UK do not pose an increased risk for dental fluorosis development. Further research is necessary into the manufacturing process of soya milks, which may influence the overall F content of the end product.

A convenient way to do valgus osteotomy for neglected fracture neck of femur.

BACKGROUND: Neglected fracture of neck of femur in young adults is a major problem in developing countries. Existing treatment options varies from osteotomy to various graft techniques (muscle pedicle, vascularized and nonvascularized fibula etc.). There is paucity of literature regarding the use of double angle barrel plate and hip screw in such cases. We conducted a prospective longitudinal observational study with displaced, neglected fracture neck of femur in young adults and compared the results with literature. OBJECTIVES: The aim of this study was to determine feasibility and effectiveness of 120° double angle barrel plate and hip screw fixation in neglected fracture neck of femur. Effectiveness of fixed 30 degree closed wedge osteotomy in neglected fracture neck of femur. METHODS: Thirty cases of neglected (more than three weeks) femoral neck fracture (Pauwel II and III) of age 20-60 years were included in the study conducted at Postgraduate Institute Of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India in year 2004-06. Average age of the patient was 35.4 years (range, 22yrs-55yrs). In all cases internal fixation was done by 120° double angle barrel plate and hip Screw. At the end of follow-up, results were evaluated according to Askin Bryan Criteria and Harris-hip score. RESULTS: Union was achieved in 28 of 30 patients. Two patients that went into nonunion were later treated with hemireplacement arthroplasty. According to Askin Bryan Criteria at the end of study, 35% patients had excellent results, 50% patients had good results. Minimum follow-up in our study was 12 months and maximum was five years. CONCLUSION: This study validates the use of double angled screw plate configuration for successful outcome in patients with neglected fracture neck of femur. Valgus osteotomy is also technically easy operation in hands of average trauma surgeon with the use of a fixed angle plate and hip screw.

Catastrophic antiphospholipid antibody syndrome in a child with thrombotic microangiopathy.

Thrombotic microangiopathic hemolytic anemia (TMHA) is not uncommon in clinical nephrology practice while antiphospholipid syndrome (APS) is uncommon. Although less than 1% of patients with APS develop catastrophic APS (CAPS), its potential lethal outcome because of thrombosis in multiple organs and subsequent multiorgan failure emphasizes its importance in nephrology practice. Here is a case of catastrophic APS in a 7-year-old girl, who presented to us with TMHA associated with antiphospholipid antibodies and subsequently died because of CAPS.

AZD9668: pharmacological characterization of a novel oral inhibitor of neutrophil elastase.

N-{[5-(methanesulfonyl)pyridin-2-yl]methyl}-6-methyl-5-(1-methyl-1H-pyrazol-5-yl)-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide (AZD9668) is a novel, oral inhibitor of neutrophil elastase (NE), an enzyme implicated in the signs, symptoms, and disease progression in NE-driven respiratory diseases such as bronchiectasis and chronic obstructive pulmonary disease via its role in the inflammatory process, mucus overproduction, and lung tissue damage. In vitro and in vivo experiments were done to evaluate the binding kinetics, potency, and selectivity of AZD9668, its effects in whole-blood and cell-based assays, and its efficacy in models of lung inflammation and damage. In contrast to earlier NE inhibitors, the interaction between AZD9668 and NE was rapidly reversible. AZD9668 was also highly selective for NE over other neutrophil-derived serine proteases. In cell-based assays, AZD9668 inhibited plasma NE activity in zymosan-stimulated whole blood. In isolated human polymorphonuclear cells, AZD9668 inhibited NE activity on the surface of stimulated cells and in the supernatant of primed, stimulated cells. AZD9668 showed good crossover potency to NE from other species. Oral administration of AZD9668 to mice or rats prevented human NE-induced lung injury, measured by lung hemorrhage, and an increase in matrix protein degradation products in bronchoalveolar lavage (BAL) fluid. In an acute smoke model, AZD9668 reduced the inflammatory response to cigarette smoke as indicated by a reduction in BAL neutrophils and interleukin-1ß. Finally, AZD9668 prevented airspace enlargement and small airway wall remodeling in guinea pigs in response to chronic tobacco smoke exposure whether dosed therapeutically or prophylactically. In summary, AZD9668 has the potential to reduce lung inflammation and the associated structural and functional changes in human diseases.

Serum fluoride and sialic acid levels in osteosarcoma.

Osteosarcoma is a rare malignant bone tumor most commonly occurring in children and young adults presenting with painful swelling. Various etiological factors for osteosarcoma are ionizing radiation, family history of bone disorders and cancer, chemicals (fluoride, beryllium, and vinyl chloride), and viruses. Status of fluoride levels in serum of osteosarcoma is still not clear. Recent reports have indicated that there is a link between fluoride exposure and osteosarcoma. Glycoproteins and glycosaminoglycans are an integral part of bone and prolonged exposure to fluoride for long duration has been shown to cause degradation of collagen and ground substance in bones. The present study was planned to analyze serum fluoride, sialic acid, calcium, phosphorus, and alkaline phosphatase levels in 25 patients of osteosarcoma and age- and sex-matched subjects with bone-forming tumours other than osteosarcoma and musculo-skeletal pain (controls, 25 each). Fluoride levels were analyzed by ISE and sialic acid was analyzed by Warren's method. Mean serum fluoride concentration was found to be significantly higher in patients with osteosarcoma as compared to the other two groups. The mean value of flouride in patients with other bone-forming tumors was approximately 50% of the group of osteosarcoma; however, it was significantly higher when compared with patients of group I. Serum sialic acid concentration was found to be significantly raised in patients with osteosarcoma as well as in the group with other bone-forming tumors as compared to the group of controls. There was, however, no significant difference in the group of patients of osteosarcoma when compared with group of patients with other bone-forming tumors. These results showing higher level of fluoride with osteosarcoma compared to others suggesting a role of fluoride in the disease.

Vascular malformation of the jejunum presenting as obscure gastrointestinal haemorrhage: detection with multidetector CT angiography.

Vascular malformation of the small bowel is an uncommon cause of gastrointestinal haemorrhage. Phlebectasia or venous ectasia is a rare benign vascular anomaly of the gastrointestinal tract. We report a 39-year-old Egyptian man presenting with multiple jejunal phlebectasia, liver haemangioma and port-wine naevus. Despite recurrent melaena, the results of various routine investigations, including repeated endoscopic procedure, were negative. The site and aetiology of bleeding was detected using multidetector computed tomography (MDCT) angiography and was further confirmed by double-balloon enteroscopy. This report emphasises the potential of MDCT angiography in the diagnosis of small intestine lesions presenting as obscure bleeding.

Treatment of neglected elbow dislocations with combination of speed V-Y muscleplasty and intra-articular injection of hydrocorticosone.

Neglected dislocations of the elbow are not uncommon in developing countries. We report case series of 3 cases of neglected dislocations of elbow. All the three cases were treated by combination of Speeds procedure and intraarticular injection of 25mg of hydrocorticosone acetate in 5 ml of distilled water. Mean time from injury was 5 months and mean follow-up was 10 months. According to Mayo Elbow Performance Index, 2 outcomes were excellent and 1 outcome was good.

Influence of diabetes on liver injury induced by antitubercular drugs and on silymarin hepatoprotection in rats.

Isoniazid, rifampicin and pyrazinamide during short-course chemotherapy for tuberculosis can result in liver injury. The coexistence of tuberculosis and diabetes is common in patients who receive inadequate treatment. The risk of hepatotoxicity from many toxicants is increased in diabetic rats. Silymarin provides protection against liver injury caused by many hepatotoxicants, including antitubercular drugs (ATDs). In the wake of increased severity of ATD-induced hepatotoxicity in diabetes we report here the results of a study on the influence of diabetes on silymarin hepatoprotection in rats. Rats with diabetes induced via intraperitoneally injected streptozotocin (50 mg/kg), nondiabetic rats and insulin-treated diabetic rats received isoniazid (7.5 mg/kg/day), rifampicin (10 mg/kg/day) and pyrazinamide (35 mg/kg/day) orally (p.o.) with or without silymarin (100 mg/kg/day p.o.) treatment for 45 days. Compared to nondiabetic rats, liver function tests and histological changes of liver revealed exaggerated liver injury in diabetic rats caused by ATDs which was evident by 5- to 8-fold increases in serum levels of marker enzymes (aspartate and alanine aminotransferase, alkaline phosphatase and gamma-glutamyltranspeptidase) and 1- to 2-fold increases in bilirubin accompanied by a 2-fold decrease in total serum proteins, intense fatty and inflammatory infiltrations, necrosis and fibrosis. Coadministration of silymarin provided protection against ATD hepatotoxicity in all animals. However, insulin-treated diabetic animals showed greater silymarin-induced hepatoprotection against ATD-induced liver injury, which was characterized by near normal levels of marker enzymes, an increase in total proteins and normal hepatic structure. These results thus indicate that diabetes exaggerates ATD-induced liver injury and attenuates silymarin-induced hepatoprotection. However, insulin treatment for diabetes offers greater silymarin-induced hepatoprotection against ATD-induced liver injury.

Stretch-induced MAP kinase activation in cardiac myocytes: differential regulation through beta1-integrin and focal adhesion kinase.

Mitogen-activated protein (MAP) kinases have been implicated in hemodynamic load induced heart failure. Both angiotensin II (Ang II) and mechanical stretch activate MAP kinases in cardiac myocytes. In this study, we used a neonatal rat ventricular myocyte (NRVM) model to determine the role of focal-adhesion kinase (FAK) in beta1 integrin mediated MAP kinase activation in response to mechanical stretch in presence and absence of Ang II receptor blockade (ATB). NRVM plated on deformable membranes coated with collagen IV were exposed to 20% equiaxial static-stretch. beta1 integrin signaling was blocked by adenovirus-mediated expression of a dominant-negative form of beta1D integrin (tac-beta1D). FAK signaling was disrupted by infecting NRVM with adenovirus expressing FAK-related non-kinase (FRNK). Western blot analysis was used to assess the phosphorylation of MAP kinases. In the presence and absence of ATB, mechanical stretch caused maximal phosphorylation of ERK, p38 and JNK at 5 min, which was significantly attenuated in NRVM expressing tac-beta1D. In the presence of ATB, FRNK overexpression significantly increased basal phosphorylation of ERK (40.2+/-8.6% P<0.05), p38 (39.5+/-11.7%, P<0.05), JNK (86+/-29.4%, P<0.05) and stretch-induced p38 (48.1+/-8.7%, P<0.05) and JNK (85.0+/-19.4%, P<0.05) phosphorylation. However, in the absence of ATB, FRNK overexpression significantly reduced basal and stretch-induced phosphorylation of only ERK. Examination of FAK activation revealed that beta1 integrin was required for stretch-induced phosphorylation of FAK at Y397 and Y925, but not Y861. In summary, mechanical stretch-activated ERK1/2, p38 and JNK through FAK independent and dependent mechanisms. Beta1 integrin was required for FAK independent activation of all three MAP kinases, whereas cross-talk between beta1 integrin and Ang II receptors mediated FAK dependent regulation of ERK1/2.

Progressive pseudorheumatoid chondrodysplasia of childhood.

Progressive pseudorheumatoid chondrodysplasia is an autosomal recessively inherited skeletal dysplasia, characterised by platyspondyly and progressive arthropathy. We report a 26-year-old woman who presented with a history of waddling gait, progressive restriction of movements of several joints and swelling of interphalangeal joints since her late childhood. She was diagnosed to have progressive pseudorheumatoid chondrodysplasia associated with synovial osteochondromatosis.

DOTS centre at a tertiary care teaching hospital: lessons learned and future directions.

BACKGROUND: In 1993, Government of India started the Revised National Tuberculosis Control Programme (RNTCP). A model Directly Observed Therapy, Short-Course (DOTS) centre was established at the All India Institute of Medical Sciences (AIIMS) to (i) identify the challenges and opportunities in establishing DOTS centres at tertiary care facilities, (ii) to teach the strategies of RNTCP to medical and paramedical staff, and (iii) to undertake relevant operational research connected with tuberculosis (TB) treatment and control. In this communication, we describe the experience of establishing a DOTS centre at India's premier medical institute and discuss the lessons learned. METHODS: Since September 2001 through November 2002 AIIMS employees and their dependants diagnosed with tuberculosis were enrolled for treatment at AIIMS DOTS centre. One hundred sixty-eight patients were diagnosed as suffering from tuberculosis. Of these 49 patients were referred out and remaining 119 patients were treated at AIIMS DOTS centre. RESULTS: Treatment success was achieved in 80% (20/25) of new smear positive cases and the DOTS centre achieved other targets set up by the RNTCP. As the results of the pilot study at AIIMS DOTS centre were favourable, the facilities of AIIMS DOTS centre were extended to the general public from September 2002 onwards. CONCLUSION: Despite tremendous patient load at tertiary care facilities, it is possible to achieve targets established by the RNTCP. However, additional research needs to be conducted especially relating to drug resistance and surrogate markers of failure under RNTCP.

Asparagus racemosus--an update.

Asparagus racemosus (Shatavari) is recommended in Ayurvedic texts for prevention and treatment of gastric ulcers, dyspepsia and as a galactogogue. A. racemosus has also been used successfully by some Ayurvedic practitioners for nervous disorders, inflammation, liver diseases and certain infectious diseases. However, no scientific proof justifying aforementioned uses of root extract of A. racemosus is available so far. Recently few reports are available demonstrating beneficial effects of alcoholic and water extracts of the root of A. racemosus in some clinical conditions and experimentally induced diseases, e.g. galactogogue effect, antihepatotoxic and immunomodulatory activities. The present article includes the detailed exploration of pharmacological properties of the root extract of A. racemosus reported so far.

Eye metastasis form urothelial tumours.

Obit is an infrequent site of metastasis from urothelial tumours. To the best of our knowledge there are less than ten case reports of orbital or choroidal metastases from urothelial tumours reported in English medical literature. On the basis of review of these reports (Table 1) and experience in managing two more cases, it is emphasized that non-specific eye symptoms in patients of urothelial tumours need thorough ophthalmological and radiological evaluation. Herein, we present case descriptions, along with pathophsiology; and review of literature to highlight the need for early diagnosis and prompt management of this rare clinical event.