Preventive hepatology at AIIMS Rishikesh: Delivering comprehensive and integrated care for liver diseases in Northern state of India.

Globally, liver diseases accounts for 4% of all deaths. Annually, over 2 million deaths occur due to preventable causes of chronic liver diseases and liver cancer like fatty liver diseases (alcoholic or non alcoholic) and viral hepatitis B and C. The burden of chronic liver diseases are increasing, and the epidemiology and demographics of people affected by these diseases are changing. Policy changes, vaccination, screening, lifestyle changes and public health awareness is the key to curb down liver disaeses. To achieve the ultimate goal of reducing mortality and linkage to care for those who need specialized care for liver disease, it is vital to have dedicated preventive hepatology clinics in sync with existing liver or gastroenterology clinics at tertary care level.

Community Screening for High-Risk Human Papilloma Virus Infection using Self-Sampling and 'Point-Of-Care' Test.

OBJECTIVE: HR-HPV types 16 and 18 are responsible for pre-invasive and invasive lesions of the cervix, accounting for 70-80% of the total subtypes. The aim of this study was to investigate the prevalence of high-risk HPV subtypes 16 and 18 in self-collected vaginal samples using real-time micro-PCR and to study the acceptability of self-sampling. METHODS: Eligible women (30-65 years) were screened from a semi-urban area of Uttarakhand (India) using self-sampling. High-risk HPV genotypes (16/31 and 18/45) were tested using real-time micro-PCR technique with results available in one hour. The positive results were validated by standard RT-PCR for high-risk HPV 16, 18, separately and for 12 other high-risk genotypes, combined. Ease of the procedure, level of comfort, and recommendation to other women were studied and the acceptability of self-sampling was analyzed using the Likert scale. RESULT: Of 975 eligible women screened, 45 participants tested positive for HR-HPV (16/31,18/45) using real-time micro-PCR with a prevalence of 4.6%. Positive samples were further tested through routine RT-PCR and 60% were found to be HR-HPV 16 and 18 positive. For self-sampling, 96.72% (n=943) participants were 'very satisfied' and 94.15% (n=918) found self-sampling to be 'very comfortable' and 88.51% (n=863) stated that they will strongly recommend this test to other eligible women in the community. CONCLUSION: We conclude that HR-HPV testing with limited genotyping showed a prevalence of 4.6%, 60% of these were HPV 16/18 positive. Point of care testing was feasible in the community and self-sampling was acceptable.

Development and content validation of yoga module for the mental health of NICU mothers.

BACKGROUND: Postnatal yoga has been found to be effective for maternal mental health management. But a validated yoga module for the mental health of early postpartum mothers with infants admitted to the Neonatal Intensive Care Unit (NICU) is lacking. AIM: To design and validate a yoga module for the mental health of early postpartum mothers having infants admitted to the NICU. MATERIALS AND METHODS: First phase: A yoga module was designed through a review of published research articles and yogic texts for NICU mothers. Second phase: thirty-eight yoga experts validated the yoga module. Lawshe's formula was used to calculate each item's content validity ratio (CVR). The intra-class correlation coefficient was determined for the validated yoga module. Third phase: The validated yoga module was pilot-tested with a sample size of 20 NICU mothers. RESULTS: Thirty-eight yoga experts validated the yoga module for NICU mothers. Thirteen practices included in the module indicated good content validity (cutoff value: 0.316). The module's content validity index (CVI) and intra-class correlation coefficient were 0.672 and 0.924, respectively. Ten days of practicing the yoga module resulted in a significant reduction in maternal stress levels in the yoga group (p < 0.001) compared to the control group (p = 0.427). CONCLUSION: The present study suggests good content validity of the yoga module for the mental health of NICU mothers. However, future randomized controlled trials must be carried out to determine both the feasibility and clinical efficacy of the Yoga Module for NICU mothers.

Factors associated with unexplained sudden deaths among adults aged 18-45 years in India - A multicentric matched case-control study.

BACKGROUND OBJECTIVES: In view of anecdotal reports of sudden unexplained deaths in India's apparently healthy young adults, linking to coronavirus disease 2019 (COVID-19) infection or vaccination, we determined the factors associated with such deaths in individuals aged 18-45 years through a multicentric matched case-control study. METHODS: This study was conducted through participation of 47 tertiary care hospitals across India. Cases were apparently healthy individuals aged 18-45 years without any known co-morbidity, who suddenly (<24 h of hospitalization or seen apparently healthy 24 h before death) died of unexplained causes during 1 st October 2021-31 st March 2023. Four controls were included per case matched for age, gender and neighborhood. We interviewed/perused records to collect data on COVID-19 vaccination/infection and post-COVID-19 conditions, family history of sudden death, smoking, recreational drug use, alcohol frequency and binge drinking and vigorous-intensity physical activity two days before death/interviews. We developed regression models considering COVID-19 vaccination ≤42 days before outcome, any vaccine received anytime and vaccine doses to compute an adjusted matched odds ratio (aOR) with 95 per cent confidence interval (CI). RESULTS: Seven hundred twenty nine cases and 2916 controls were included in the analysis. Receipt of at least one dose of COVID-19 vaccine lowered the odds [aOR (95% CI)] for unexplained sudden death [0.58 (0.37, 0.92)], whereas past COVID-19 hospitalization [3.8 (1.36, 10.61)], family history of sudden death [2.53 (1.52, 4.21)], binge drinking 48 h before death/interview [5.29 (2.57, 10.89)], use of recreational drug/substance [2.92 (1.1, 7.71)] and performing vigorous-intensity physical activity 48 h before death/interview [3.7 (1.36, 10.05)] were positively associated. Two doses lowered the odds of unexplained sudden death [0.51 (0.28, 0.91)], whereas single dose did not. INTERPRETATION CONCLUSIONS: COVID-19 vaccination did not increase the risk of unexplained sudden death among young adults in India. Past COVID-19 hospitalization, family history of sudden death and certain lifestyle behaviors increased the likelihood of unexplained sudden death.

National viral hepatitis control program in India: Call for update.

Viral hepatitis is a serious yet manageable and preventable public health menace that infects about 3 million of people and leads to 1.1 million deaths worldwide every year. An acute episode of viral hepatitis usually subsides on its own, however, if not intervened timely, chronic infection puts people at risk of cirrhosis, liver cancer, and eventually death. In 2015, the global community allied to tackle viral hepatitis, as a result of which combating viral hepatitis target was included in the sustainable development goals (SDGs), and the World Health Organisation (WHO) constituted the first-ever global health sector strategy on viral hepatitis for 2016 to 2021 which is also renewed recently. Conforming to the global commitment, India launched the National Viral Hepatitis Control Program in the year 2018 with the aim to eliminate viral hepatitis as a public health threat by the year 2030. In the Subsequent years, WHO and various other international societies have released updated recommendations with respect to vaccination, prevention of mother-to-child transmission, strategies to increase testing uptake including self-testing, newer diagnostics including point of care and reflex testing approaches, simplified treatment algorithms, expanded treatment eligibility criteria, and simplified service delivery models. With the program being in its fifth year of implementation, there is a need to revamp the operational guidelines based on various global evidence-based advancements in order to attain the ambitious elimination goal by 2030.

Systemic treatments in Parthenium dermatitis: A systematic review and meta-analysis.

Parthenium dermatitis is the commonest form of plant dermatitis in India, caused by the plant Parthenium hysterophorus. Systemic immunosuppressives are commonly employed in its treatment. However, there is a relative lack of comparative head-to-head trials. This study was done to assess the relative efficacy and safety of systemic treatments in Parthenium dermatitis. We systematically reviewed all the published studies investigating the safety and efficacy of systemic treatments for Parthenium dermatitis in the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and clinical trial registries. Treatment benefit data were tabulated based on outcome measures of scoring systems. The quality of evidence for each outcome was assessed by Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria for meta-analysis. The pooled Standardized mean difference (SMD) for case series and comparative studies based on clinical severity score (CSS) for azathioprine was 4.007 (95% CI (Confidence interval): 3.141, 4.873) and 0.746 (95% CI: 0.139, 1.352), respectively. About 88.8% (95% CI: 76.8%, 100.8%, p = 0.076) of the patients had excellent or a good response to azathioprine. Our meta-analysis shows that azathioprine has the highest level of evidence in the treatment of Parthenium dermatitis.

Urodynamics in the evaluation of lower urinary tract symptoms in young adult men: A systematic review.

Introduction: This review aims to systematically evaluate the available evidence on the different urodynamic diagnoses of lower urinary tract symptoms (LUTS) in young adult men aged 18-50 years and to summarize the various urodynamic parameters based on these diagnoses. Methods: This systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement and the search was performed in PubMed, Embase, and Cochrane library from inception till September 2021. A total of 295 records were identified using a combination of keywords such as LUTS, urodynamics (UDS), and young males. The review was registered in PROSPERO (CRD42021214045). Results: All the ten studies, which were included in this analysis, categorised the patients into either of the four primary diagnoses after the UDS - primary bladder neck obstruction (PBNO), dysfunctional voiding, detrusor underactivity (DU), or detrusor overactivity. Five of these studies used the conventional UDS, and in the other five a video UDS was performed. The most common abnormality on the conventional UDS was DU with a pooled estimate of 0.24 (95% confidence interval [CI] - 0.104-0.463, I2-95.35, (τ2-1.07). The most common abnormality on the video UDS was PBNO with a pooled estimate of 0.49 (95% CI - 0.413-0.580, I2-66.59, 2-0.09). The point estimates of various UDS parameters were also recorded. Conclusion: A urodynamic diagnosis was possible in 79% and 98% of the young men who underwent a conventional UDS or a video UDS, respectively. However, the men subjected to the conventional UDS and the video UDS had significant differences in their primary urodynamic diagnostic label. These results will help to plan future trials for the evaluation and management of LUTS in young men.

Evaluating diaphragmatic dysfunction and predicting non-invasive ventilation failure in acute exacerbation of chronic obstructive pulmonary disease in India.

BACKGROUND: Baseline diaphragmatic dysfunction (DD) at the initiation of non-invasive ventilation (NIV) correlates positively with subsequent intubation. We investigated the utility of DD detected 2 hours after NIV initiation in estimating NIV failure in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients. METHODS: In a prospective-cohort design, we enrolled 60 consecutive patients with AECOPD initiated on NIV at intensive care unit admission, and NIV failure events were noted. The DD was assessed at baseline (T1 timepoint) and 2 hours after initiating NIV (T2 timepoint). We defined DD as ultrasound-assessed change in diaphragmatic thickness (ΔTDI) <20% (predefined criteria [PC]) or its cut-off that predicts NIV failure (calculated criteria [CC]) at both timepoints. A predictive-regression analysis was reported. RESULTS: In total, 32 patients developed NIV failure, nine within 2 hours of NIV and remaining in next 6 days. The ∆TDI cut-off that predicted NIV failure (DD-CC) at T1 was ≤19.04% (area under the curve [AUC], 0.73; sensitivity, 50%; specificity, 85.71%; accuracy; 66.67%), while that at T2 was ≤35.3% (AUC, 0.75; sensitivity, 95.65%; specificity, 57.14%; accuracy, 74.51%; hazard ratio, 19.55). The NIV failure rate was 35.1% in those with normal diaphragmatic function by PC (T2) versus 5.9% by CC (T2). The odds ratio for NIV failure with DD criteria ≤35.3 and <20 at T2 was 29.33 and 4.61, while that for ≤19.04 and <20 at T1 was 6, respectively. CONCLUSIONS: The DD criterion of ≤35.3 (T2) had a better diagnostic profile compared to baseline and PC in prediction of NIV failure.

Computed tomography virtual oesophagography for the grading of oesophageal varices in cirrhotic liver disease patients with upper gastrointestinal endoscopic examination as the gold standard: a diagnostic validation study.

Purpose: Virtual endoscopy is a postprocessing method using three-dimensional computed tomography (CT), which produces views of the inner surfaces of the human body like those produced by fibreoptic endoscopy. To evaluate and categorise patients who require medical or endoscopic band ligation to prevent oesophageal variceal bleed, a less invasive, less expensive, better tolerated, and more sensitive modality is required, as well as to reduce the use of invasive procedures in the follow-up of patients who do not require endoscopic variceal band ligation. Material and methods: A cross-sectional study was conducted in the Department of Radiodiagnosis in association with the Department of Gastroenterology. The study was conducted over a period of 18 months from July 2020 to January 2022. The sample size was calculated as 62 patients. Patients were recruited on the basis of inclusion and exclusion criteria after giving informed consent. CT virtual endoscopy was performed through a dedicated protocol. Classification of variceal grading was done independently by a radiologist and endoscopist who were blinded to each other's findings. Results: The diagnostic performance of oesophageal varices detection by CT virtual oesophagography was good, with sensitivity: 86%, specificity: 90%, PPV: 98%, NPV: 56%, and diagnostic accuracy: 87%. There was substantial agreement between the 2 methods, and this agreement was statistically significant (Cohen's k = 0.616, p ≤ 0.001). Conclusions: Based on our findings, we conclude that the current study has the potential to change the way chronic liver disease is managed, as well as generate similar medical research endeavours. A multicentric study with a large number of patients is needed to improve the experience with this modality.

Comparison of clinico-radiological profile, optical coherence tomography parameters, and outcome in MOGAD and Neuromyelitis optica spectrum disorder subtypes: A prospective observational study.

Objectives: The objectives of the study were to compare the clinico-radiological profile, optical coherence tomography (OCT) parameters and outcome in Myelin Oligodendrocyte Glycoprotein-IgG-associated disorders (MOGAD) and Neuromyelitis Optica Spectrum disorder subtypes. Materials and Methods: This prospective study involved collection of data regarding neurological assessment, neuroimaging, cerebrospinal fluid analysis, OCT parameters, treatment and outcome. Disease severity and disability were assessed using Expanded Disability Status Scale and modified Rankin scale. Patients were categorized into aquaporin-4 (AQP4+), MOGAD, and double negative (DN; both AQP4 and MOG negative). Results: Among 31 patients included, 42% were AQP4+, 32.2% were MOGAD, and 25.7% were DN. The median age at onset was comparable (AQP4+ vs. MOGAD vs. DN = 28 years vs. 24.4 years vs. 31.5years; P = 0.31). Females predominated in AQP4+ compared to MOGAD group (76.9% vs. 30%; P = 0.02). Majority of patients (73.5%) had a relapsing course with a median of two (range = 1-9) relapses. Ninety-nine demyelinating events occurred: Transverse myelitis (TM) in 60/99 (60.6%), optic neuritis (ON) in 43/99 (43.4%), area postrema (AP) syndrome in 20/99 (20.1%), and optico-spinal syndrome in 10/99 (10.1%). ON was common in MOGAD than AQP4+ patients (58.6% vs. 32.1%; P = 0.03). Spinal cord and brain lesions on magnetic resonance imaging (MRI) were seen in 90.3% and 54.8% patients, respectively. A significantly higher proportion of AQP4+ patients showed longitudinally extensive transverse myelitis as compared to MOGAD group (69.2 % vs. 20 %; P = 0.04), specifically involving dorsal cord (92.3% vs. 50%; P = 0.02). MRI brain lesions, especially involving AP, was frequent in DN than MOGAD (47.1% vs. 6.9%; P = 0.003) and AQP4+ (47.1% vs. 18.9%; P = 0.03) patients. AQP4+ group showed significant nasal RNFL thinning on OCT (P = 0.04). Although 6-month good functional outcome was better in MOGAD than DN and AQP4+ (80% vs. 71.4% vs. 41.7%) groups, they were comparable (P = 0.13). Conclusion: Nearly three-fourth of our patients showed a relapsing course, with TM being the most common clinical presentation. AQP4+ group showed female preponderance, frequent dorsal cord longitudinally extensive transverse myelitis, less frequent ON, and greater nasal RNFL thinning compared to MOGAD group. MRI brain lesions were more common in DN patients. All three groups exhibited good response to pulse corticosteroids and showed a comparable functional outcome at 6-month follow-up.

Predictors of Mortality among Patients Hospitalized with COVID-19 during the First Wave in India: A Multisite Case-Control Study.

Severe acute respiratory syndrome coronavirus 2 disease (COVID-19) has caused more than 6 million deaths globally. Understanding predictors of mortality will help in prioritizing patient care and preventive approaches. This was a multicentric, unmatched, hospital-based case-control study conducted in nine teaching hospitals in India. Cases were microbiologically confirmed COVID-19 patients who died in the hospital during the period of study and controls were microbiologically confirmed COVID-19 patients who were discharged from the same hospital after recovery. Cases were recruited sequentially from March 2020 until December-March 2021. All information regarding cases and controls was extracted retrospectively from the medical records of patients by trained physicians. Univariable and multivariable logistic regression was done to assess the association between various predictor variables and deaths due to COVID-19. A total of 2,431 patients (1,137 cases and 1,294 controls) were included in the study. The mean age of patients was 52.8 years (SD: 16.5 years), and 32.1% were females. Breathlessness was the most common symptom at the time of admission (53.2%). Increasing age (adjusted odds ratio [aOR]: 46-59 years, 3.4 [95% CI: 1.5-7.7]; 60-74 years, 4.1 [95% CI: 1.7-9.5]; and ≥ 75 years, 11.0 [95% CI: 4.0-30.6]); preexisting diabetes mellitus (aOR: 1.9 [95% CI: 1.2-2.9]); malignancy (aOR: 3.1 [95% CI: 1.3-7.8]); pulmonary tuberculosis (aOR: 3.3 [95% CI: 1.2-8.8]); breathlessness at the time of admission (aOR: 2.2 [95% CI: 1.4-3.5]); high quick Sequential Organ Failure Assessment score at the time of admission (aOR: 5.6 [95% CI: 2.7-11.4]); and oxygen saturation < 94% at the time of admission (aOR: 2.5 [95% CI: 1.6-3.9]) were associated with mortality due to COVID-19. These results can be used to prioritize patients who are at increased risk of death and to rationalize therapy to reduce mortality due to COVID-19.

Cost-effectiveness of adrenocorticotropic hormone injection and oral prednisolone in patients with West syndrome: A comparative analysis.

Objectives: This study aims to compare the cost-effectiveness of oral prednisolone and adrenocorticotropic hormone injection in West syndrome patients, the two most common hormonal therapies used for this condition. Materials and Methods: In this prospective and observational study, we documented sociodemographic, epilepsy, and development-related variables at baseline and up to 6 months after starting hormonal therapy, in all consecutive eligible patients of WS between August 2019 and June 2021, apart from the direct medical and non-medical costs and indirect health-care costs. We selected cost per quality-adjusted life-year (QALY) gained, per one patient with spasm freedom, one positive responder (>50% reduction in spasms), one relapse-free patient, and one patient with development gain. We determined whether incremental cost-effectiveness ratio for these parameters crossed the threshold value in base-case analysis and alternate scenario analysis. Results: Out of 52 patients screened, 38 and 13 patients enrolled in ACTH and prednisolone group. On D28, 76% and 71% achieved spasm cessation (P = 0.78) and the total cost of treatment was INR 19783 and 8956 (P = 0.01), in ACTH and prednisolone group respectively. For all pre-specified parameters, the cost/effectiveness ratios including cost/QALY gain were higher in ACTH group and the corresponding ICER values for all these parameters crossed the threshold cost value of INR 148,777 in base-case analysis and also in alternative scenario analysis. Conclusion: Treatment with oral prednisolone is more cost-effective as compared to ACTH injection for children with WS.

Does left atrial appendage morphology and dimension differ amongst etiological stroke subtypes in patients without known atrial fibrillation? Results from the left atrial appendage morphology and dimension assessment by TEE in patients with stroke without known atrial fibrillation (LAMDA-STROKE) study.

CONTEXT: Complex left atrial appendage (LAA) morphology is increasingly associated with cryptogenic ischemic stroke as compared to cardioembolic stroke due to atrial fibrillation (AF). However, data on such an association in patients with other etiological stroke subtypes in the absence of AF is limited. AIM: The study aimed to assess the LAA morphology, dimension and other echocardiographic parameters by transesophageal echocardiography (TEE) in patients with embolic stroke of undetermined source (ESUS) and compare it with other etiological stroke subtypes without known AF. METHODS: This was a single-Centre, observational study involving comparison of echocardiographic parameters including LAA morphology and dimension in ESUS patients (group A; n = 30) with other etiological stroke subtypes i.e., TOAST (Trial of Org 10172 in Acute Stroke Treatment) class I-IV without AF (group B; n = 30). RESULTS: Complex LAA morphology was predominant in group A (18 patients in group A versus 5 patients in group B, p-Value = 0.001). Mean LAA orifice diameter (15.3 + 3.5 mm in group A versus 17 + 2.0 mm in group B, p-Value = 0.027) and LAA depth were significantly lower in group A (28.4 + 6.6 mm in group A versus 31.7 + 4.3 mm in group B, p-Value = 0.026). Out of these three parameters only complex LAA morphology was found to be independently associated with ESUS [OR = 6.003, 95% CI {1.225-29.417}, p = 0.027]. CONCLUSION: Complex LAA morphology is a predominant feature in ischemic stroke patients with ESUS and may contribute to an increased risk of stroke in these patients.

Role of diffusion kurtosis imaging in evaluating microstructural changes in spinal cord of patients with cervical spondylosis.

STUDY DESIGN: Analytical cross-sectional study. PURPOSE: To study the role of diffusion kurtosis imaging (DKI) in evaluating microstructural changes in patients with cervical spondylosis. OVERVIEW OF LITERATURE: Cervical spondylosis is a common progressive degenerative disorder of the spine. Conventional magnetic resonance imaging (MRI) can only detect the changes in the spinal cord once there are visual signal changes; hence, it underestimates the extent of the injury. Newer imaging techniques like Diffusion Tensor and Kurtosis Imaging can evaluate the microstructural changes in cervical spinal cord before the obvious signal changes appear. METHODS: Conventional MRI, diffusion tensor imaging (DTI), and DKI scans were performed for 90 cervical spondylosis patients on 1.5-T MR Siemens Magnetom aera after obtaining informed consent. Eight patients were excluded due to poor image quality. Fractional anisotropy (FA) colour maps and diffusion kurtosis (DK) maps corresponding to spinal cord cross sections at C2-C3 intervertebral disc level (control) and at the most stenotic levels were obtained. Modified Japanese Orthopaedic Association (mJOA) scoring was used for clinical assessment of the spinal cord function. The changes in DTI and DKI parameters and their correlation with mJOA scores were analysed by SPSS 23 software. RESULTS: In our study, mean FA and mean kurtosis (MK) values at the stenotic level (0.54, 1.02) were significantly lower than values at the non-stenotic segment (0.70, 1.27). The mean diffusivity (MD) value at the stenotic segment (1.25) was significantly higher than in the non-stenotic segment (1.09). We also observed a strong positive correlation between mJOA score and FA and MK values and a negative correlation between mJOA score and MD values, suggesting a correlation of FA, MK, and MD with the clinical severity of the disease. CONCLUSION: Addition of DTI and DKI sequences helps in early identification of the disease without any additional cost incurred by the patient.

Reconstructive techniques following low anterior resection for carcinoma of the rectum: meta-analysis.

BACKGROUND: Multiple trials have compared reconstruction techniques used following the resection of distal rectal cancers, including straight colorectal anastomosis (SCA), colonic J pouch (CJP), side-to-end anastomosis (SEA), and transverse coloplasty (TCP). The latest meta-analysis on the subject concluded that all the reservoir techniques produce equally good surgical and functional outcomes compared with SCA. Numerous trials have been published in this regard subsequently. Hence, a network analysis (NMA) was performed to rank these techniques. METHODS: A literature search of MEDLINE, Embase, and the Cochrane Library from their inception until April 2021 was conducted to identify randomized trials. Functional and surgical outcome data were pooled. ORs and standardized mean differences (MDs) were used as pooled effect size measures. A frequentist NMA model was used. RESULTS: Thirty-two trials met the eligibility criteria comprising 3072 patients. CJP showed better functional outcomes, such as low stool frequency and better incontinence score, both in the short term (stool frequency, MD -2.06, P < 0.001; incontinence, MD -1.17, P = 0.007) and intermediate term (stool frequency, MD -0.81, P = 0.021; incontinence MD -0.56, P = 0.083). Patients with an SEA (long-term OR 4.37; P = 0.030) or TCP (long-term OR 5.79; P < 0.001) used more antidiarrheal medications constantly. The urgency and sensation of incomplete evacuation favoured CJP in the short term. TCP was associated with a higher risk of anastomotic leakage (OR 12.85; P < 0.001) and stricture (OR 3.21; P = 0.012). CONCLUSION: Because of its better functional outcomes, CJP should be the reconstruction technique of choice. TCP showed increased anastomotic leak and stricture rates, warranting judicious use.

Ultrasonographic Evaluation of Thickness and Stiffness of Achilles Tendon and Plantar Fascia in Type 2 Diabetics Patients: A Cross-sectional Observation Study.

Background: Diabetes mellitus (DM) can contribute to the development of foot ulcers, a known complication of DM with a high financial and social burden. Achilles tendon (AT) and plantar fascia (PF) are well known to play an important role in foot biomechanics. The present study focuses on the alteration in thickness and stiffness of the AT and PF in Type 2 DM patients compared with the normal controls. Methods: A cross-sectional observational study was conducted with 55 DM patients and 55 healthy volunteers as controls. The thickness of the AT and PF were measured using B-mode ultrasound and stiffness was measured using shear wave elastography. Both the thickness and stiffness in the patient group and controls were compared. The values were also compared with the clinical and demographic profiles of the patients. Results: DM patients had considerably thicker AT and PF than controls (P < 0.05); mean values of AT thickness for DM patients and controls were 5.66 ± 0.54 mm and 4.61 ± 0.39 mm, respectively, and for PF were 2.53 ± 0.51 mm and 1.97 ± 0.19 mm, respectively. Furthermore, the stiffness of AT and PF was significantly (P < 0.05) lower in DM patients compared to controls, suggestive of softening of AT and PF in Type 2 DM patients. Mean values of shear wave velocity for DM patients and controls in AT were 5.53 ± 0.54 m/s and 7.25 ± 0.61 m/s, respectively, and for PF, 4.53 ± 0.89 m/s and 6.28 ± 0.88 m/s, respectively. Conclusion: We conclude that there is softening and thickening of the AT and PF in Type 2 DM patients, which can impair foot biomechanics.