Revised Algorithmic Approach to Differentiate Between Nonspecific and Specific Etiologies of Chronic Terminal Ileitis.

INTRODUCTION: Chronic isolated terminal ileitis (TI) may be seen in Crohn's disease (CD) and intestinal tuberculosis (ITB) in addition to other etiologies that may be managed symptomatically. We developed a revised algorithm to distinguish patients with a specific etiology from a nonspecific etiology. METHODS: Patients with chronic isolated TI followed up from 2007 to 2022 were retrospectively reviewed. A specific (ITB or CD) diagnosis was made based on standardized criteria, and other relevant data were collected. Using this cohort, validation of a previously suggested algorithm was conducted. Furthermore, based on the results of a univariate analysis, a multivariate analysis with bootstrap validation was used to develop a revised algorithm. RESULTS: We included 153 patients (mean age 36.9 ± 14.6 years, males-70%, median duration-1.5 years, range: 0-20 years) with chronic isolated TI of whom 109 (71.2%) received a specific diagnosis (CD-69, ITB-40). On multivariate regression and validation statistics with a combination of clinical, laboratory, radiological, and colonoscopic findings, an optimism corrected c-statistic of 0.975 and 0.958 was obtained with and without histopathological findings, respectively. Revised algorithm, based on these, showed sensitivity, specificity, positive and negative predictive values, and overall accuracy of 98.2% (95% CI: 93.5-99.8), 75.0% (95% CI: 59.7-86.8), 90.7% (95% CI: 85.4-94.2), 94.3% (95% CI: 80.5-98.5) and 91.5%(95% CI:85.9-95.4), respectively. This was more sensitive and specific than the previous algorithm (accuracy 83.9%, sensitivity 95.5%, and specificity 54.6%). DISCUSSION: We developed a revised algorithm and a multimodality approach to stratify patients with chronic isolated TI into specific and nonspecific etiologies with an excellent diagnostic accuracy, which could potentially avoid missed diagnosis and unnecessary side effects of treatment.

A case report of breast cancer and membranous nephropathy with positive anti phospholipase A2 receptor antibodies.

BACKGROUND: Testing for antibodies against podocyte phospholipase A2 receptor-1 (PLA2R) allows clinicians to accurately identify primary membranous nephropathy (MN). Secondary MN is associated with a spectrum of pathology including solid organ malignancy. PLA2R positivity in these patients occurs, although no case of PLA2R-positive MN has been definitively linked to cancer. CASE PRESENTATION: We describe a case of biopsy-proven PLA2R-positive MN, in whom invasive ductal carcinoma of the breast was discovered. The patient underwent surgery and adjuvant chemotherapy (including cyclophosphamide) and went into a sustained complete remission of her nephrotic syndrome. DISCUSSION AND CONCLUSIONS: Case series have reported PLA2R positivity in patients with solid organ malignancy associated MN. Our case is unusual as it is a breast malignancy, and the patients nephrotic syndrome and anti-PLA2Rab titres improved with treatment of the cancer. Here we report, to the best of our knowledge, the first case of oestrogen receptor-2 positive breast cancer associated with PLA2R positive MN in a young lady that was treated successfully by treating the malignancy.

Association of Sarcopenia with Health Related Quality of Life in Cirrhotics.

BACKGROUND & OBJECTIVES: Sarcopenia is one of the most common complication associated with mortality in cirrhotic patients. However, the lack of an objective and reliable method to quantify muscle mass has limited the general incorporation of sarcopenia into cirrhosis prognostic scores. In this article, we highlight crosssectional imaging-based estimation of skeletal muscle mass for diagnosing sarcopenia in cirrhotic patients and its effect on health related quality of life. METHODS: After getting ethical clearance and informed consent, all patients with cirrhosis were taken and assessed for sarcopenia using thigh muscle based index The average feather index was used in conjunction with BMI in determining the probability of sarcopenia. The CLDQ was used to assess the health related quality of life. The chi-square and Pearsons coefficient were used for analyzing correlation between sarcopenia and other variables. RESULTS & DISCUSSION: In our study, out of the 288 patients, sarcopenia was present in 132 patients (45.83%). Sarcopenia was present in 18.2% in CHILD A,42.4 % in CHID B and 90.5 % in CHILD C cirrhotics. Sarcopenia was highest in autoimmune hepatitis related cirrhosis (80%), followed by NASH (61.9%),followed by ethanol (42.4%), followed by HCV (28.5%) and HBV (16.6%). Sarcopenia had a moderate negative correlation with health related Quality of life as assessed by CLD Q particularly in relation with systemic symptoms and activity. CONCLUSION: The factors like high MELD, CHILD C cirrhosis, NASH as etiology, were associated with higher prevalence of sarcopenia.NASH related cirrhotics have high prevalance of sarcopenia even in CHILD A patients. The patients with sarcopenia were having a low overall quality of life as per CLDQ,especially in specific aspects related to systemic symptoms and activity.

Do Growing Rods for Idiopathic Early Onset Scoliosis Improve Activity and Participation for Children?

OBJECTIVE: To investigate whether growing rod surgery for children with progressive idiopathic early onset scoliosis (EOS) effects activity and participation, and investigate factors that may affect this. STUDY DESIGN: Multicenter retrospective cohort study using prospectively collected data on 60 children with idiopathic EOS and significant scoliosis (defined as a Cobb angle >40°). Thirty underwent brace treatment, and 30, growth rod surgery. Questionnaire and radiographic data were recorded at 1 year. The validated Activities Scale for Kids performance version (ASKp) questionnaire was used to measure activity and participation. RESULTS: In the brace group, Cobb angle increased from 60° to 68°. There was no change in ASKp score. In the operative group, Cobb angle decreased from 67° to 45°. ASKp decreased from 91 to 88 (P < .01). Presence of spinal pain correlated with greater reduction in activity and participation scores in both groups, as did occurrence of complications in the operative group (P < .05). Both treatments permitted growth of the immature spine. CONCLUSIONS: In children with significant idiopathic EOS (Cobb angle>40°), growth rod surgery was associated with a reduction in activity and participation and Cobb angle, whereas brace treatment was associated with an increase in Cobb angle and no change in activity and participation. Pain was the most important factor affecting activity and participation in both groups.

Shoulder linked arthroplasty in patients with obstetric brachial plexus palsy can improve quality of life and function at short-term follow-up.

BACKGROUND: Patients with obstetric brachial plexus palsy (OBPP) are prone to develop degenerative shoulder disease at a younger age than the general population. To date, no reports have been published on the complexities or outcome of shoulder arthroplasty (SA) in this unique patient group. METHODS: We reviewed of 9 SAs in 9 patients (3 men and 6 women) with OBPP with mean follow-up 5.1 years (range, 2.6-7.6 years). Patients were a mean age of 29 years (range, 16-56 years). Patients had undergone a mean of 3 previous operations (range, 2-6). All patients underwent linked constrained SA. RESULTS: The mean Oxford Shoulder Score increased from 8 (range, 3-10) preoperatively to 21 (range, 12-32) at the final follow-up (P < .001) predominantly due to pain relief. Mean range of active forward elevation and abduction improved from 35° and 39° to 46° and 45°, respectively. Patients improved significantly in 2 of 8 Short-Form 36-Item health-related quality of life domains, bodily pain (P = .013) and mental health (P = .035), and the overall physical component summary score (P = .006). Range of motion had mild improvements. Three required reoperation (33%), comprising 1 excision of heterotopic ossification, 1 trimming of a prominent screw, and 1 deltoid rupture repair. CONCLUSIONS: SA is effective at relieving pain and health-related quality of life for young patients with OBPP; however, compared with the general population, the complication rate is high and functional gains are small.

Ocular injuries in people with multiple trauma.

About 8% of all major trauma patients have eye injuries, which can have serious implications for the patients and their families. This article outlines a practical approach to the recognition, assessment and management in emergency departments of common ocular traumatic injuries. It also provides an overview of the applied anatomy, and discusses common complications.

Dysphotopsia and location of laser iridotomy: a systematic review.

This systematic review aimed to clarify the relationship between the location of laser peripheral iridotomy (LPI), a common procedure to prevent or treat angle-closure glaucoma, and the incidence of post-procedure visual disturbances known as dysphotopsias. Understanding this relationship is crucial due to the high frequency of LPIs performed and the significant impact dysphotopsia can have on vision and quality of life. Articles investigating the relationship between LPI location and dysphotopsia in at least five patients were identified via a literature search of OVID MEDLINE (1946-November 19, 2022) and EMBASE (1946-November 19, 2022). Non-comparative and non-English studies were excluded. Studies did not require a control group to be included. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and Cochrane Risk of Bias 2 (RoB2) tool were used to appraise included studies. Our review included three studies encompassing 1756 eyes from 878 patients. The location of LPI was grouped into superior (604 patients, 889 eyes), inferior (150 patients, 150 eyes), and nasal/temporal (443 patients, 717 eyes). The analysis showed no significant difference in the incidence of any new dysphotopsia types among the location groups post-LPI. Overall, the incidence of lines, ghost images, and blurring significantly increased after LPI, while halos and glare significantly decreased. In conclusion, the current literature suggests that the location of LPI has no significant relationship to the types and rates of dysphotopsia experienced thereafter. While there is a 2-3% risk of linear dysphotopsia after LPI regardless of location, LPI may also resolve pre-existing halos and glare.

Ensemble of deep convolutional neural networks is more accurate and reliable than board-certified ophthalmologists at detecting multiple diseases in retinal fundus photographs.

AIMS: To develop an algorithm to classify multiple retinal pathologies accurately and reliably from fundus photographs and to validate its performance against human experts. METHODS: We trained a deep convolutional ensemble (DCE), an ensemble of five convolutional neural networks (CNNs), to classify retinal fundus photographs into diabetic retinopathy (DR), glaucoma, age-related macular degeneration (AMD) and normal eyes. The CNN architecture was based on the InceptionV3 model, and initial weights were pretrained on the ImageNet dataset. We used 43 055 fundus images from 12 public datasets. Five trained ensembles were then tested on an 'unseen' set of 100 images. Seven board-certified ophthalmologists were asked to classify these test images. RESULTS: Board-certified ophthalmologists achieved a mean accuracy of 72.7% over all classes, while the DCE achieved a mean accuracy of 79.2% (p=0.03). The DCE had a statistically significant higher mean F1-score for DR classification compared with the ophthalmologists (76.8% vs 57.5%; p=0.01) and greater but statistically non-significant mean F1-scores for glaucoma (83.9% vs 75.7%; p=0.10), AMD (85.9% vs 85.2%; p=0.69) and normal eyes (73.0% vs 70.5%; p=0.39). The DCE had a greater mean agreement between accuracy and confident of 81.6% vs 70.3% (p<0.001). DISCUSSION: We developed a deep learning model and found that it could more accurately and reliably classify four categories of fundus images compared with board-certified ophthalmologists. This work provides proof-of-principle that an algorithm is capable of accurate and reliable recognition of multiple retinal diseases using only fundus photographs.

Minimally Invasive Glaucoma Surgery: A Review of the Literature.

Minimally invasive glaucoma surgery (MIGS) has emerged as a novel approach in the glaucoma treatment spectrum, offering a range of diverse procedures and devices aimed at reducing intraocular pressure (IOP). MIGS can be broadly classified into several categories: those that enhance trabecular outflow (Trabectome, iStent, Hydrus Microstent, Kahook Dual Blade, high frequency deep sclerotomy, and gonioscopy-assisted transluminal trabeculotomy), those that augment suprachoroidal outflow (CyPass Microstent and iStent Supra), those that target Schlemm's canal (TRAB360 and the OMNI Surgical System, Streamline, and Ab Interno Canaloplasty), and conjunctival bleb-forming procedures (EX-PRESS Glaucoma Filtration Device, Xen Gel Stent and PreserFlo MicroShunt). MIGS is considered to have a shorter surgical time and fewer severe complications when compared to traditional glaucoma surgeries such as trabeculectomy and glaucoma drainage device implantation (Ahmed, Baerveldt, and Molteno valves). This literature review comprehensively examines the distinct MIGS devices and procedures, their underlying mechanisms, and clinical outcomes, emphasizing the importance of evaluating the efficacy and complications of each approach individually. As the field of MIGS continues to evolve, it is crucial to prioritize high-quality, long-term studies to better understand the safety and effectiveness of these innovative interventions in glaucoma management.

Validation of Deauville Score for Response Evaluation in Hodgkin's Lymphoma.

Context: Positron emission tomography (PET) using F-18 fluorodeoxyglucose (FDG) for treatment monitoring in patients with lymphoma is one of the most well-developed clinical applications. Deauville five-point score (DS) is recommended for response assessment in international guidelines. DS gives the threshold for adequate or inadequate response to be adapted according to the clinical context or research question. Aims: We aimed to validate DS in Hodgkin's lymphoma (HL) by retrospectively assigning this score to F-18 FDG PET-computed tomography (CT) studies done before 2016 and analyzing its concordance with the line of management. The secondary aim was to assess the reproducibility of DS in the interpretation of PET-CT scans. Subjects and Methods: A total of 100 eligible consecutive patients underwent F-18 FDG PET-CT scans between January 2014 and December 2015. Their interim, end of treatment, and follow-up PET scans were retrospectively visually analyzed and assigned DS by three nuclear medicine physicians. Concordance was defined as agreement between the DS assigned and the line of treatment. Interobserver variability was calculated using weighted Kappa and presented with 95% confidence interval. Results: Among 212 scans assigned DS, 165 scans showed agreement between the DS and line of treatment. Of these, 95.2% of scans scored DS 1-3 were kept on following or the same treatment plan was continued and patients did well. Among the scans that showed discordance, 24 scans scored DS 4/5 were continued on the same treatment regimen and the next assessment showed disease progression. Conclusions: Our study confirmed that DS is a useful tool to aid in reporting F-18 FDG PET-CT in the management of HL with good positive and negative predictive values. This study also demonstrated good interobserver agreement.

Analysis of discordant PET and CT findings in 18F-FDG PET-CT scans in the management of oncology patients.

BACKGROUND: Discordant findings are often noted between PET-CT and CT images of 18F-FDG PET-CT scans and cause ambiguity in image interpretation. This study aimed at determining the significance of these findings in the management of oncology patients. CONTEXT: Discordant findings are often noted between PET-CT and CT images of 18F-FDG PET-CT scans and cause ambiguity in image interpretation. AIM: This study aimed at determining the significance of these findings in the management of oncology patients. METHODS: This was an observational, descriptive study. Hence, retrospective analysis of all discordant findings in oncology patients undergoing a PETCT imaging between Jan 2013 and Jan 2016 was done. Those patients who had a follow-up period of minimum 1 year in either of the following forms - repeat PETCT imaging, other radiological imaging, clinical, or histopathological evidence were included. From all the discordant lesions, the sensitivity, specificity, positive predictive, negative predictive value, and accuracy of both PET-CT and CT modalities were determined. RESULTS: Of 348 discordant lesions, 16.7% was noted in soft tissues, 25% in viscera, 28.7% in lungs, 14.1% in lymph nodes, and 15.5% in bones. At the end of follow-up, 15.2% lesions were PET true positive, 57.5% PET true negative, 10.1% CT true positive lesions, 13.8% CT true negative, and 3.4% were inconclusive. CONCLUSION: 18F-FDG PET-CT is superior to CT imaging and should be considered as the first-line imaging modality in oncology patients.

Anesthetic Considerations for Cataract Surgery in Patients with Parkinson's Disease: A Narrative Review.

Parkinson's disease (PD) is a chronic neurological degenerative disease affecting the central nervous system, which is responsible for progressive disorders such as slow movements, tremors, rigidity, and cognitive disorders. There are no specific recommendations and guidelines for anesthetic management of patients with PD undergoing ophthalmic procedures. This narrative review aims to summarise the anesthetic considerations in patients with PD presenting for cataract surgery.

Systematic Review and Meta-analysis: Does Anterior-Posterior Spinal Fusion Still have a Role in Severe Thoracic Adolescent Idiopathic Scoliosis?

Background: Debate exists as to whether anterior-posterior spinal fusion (APSF), rather than posterior-only spinal fusion (PSF), provides benefit for treating severe thoracic adolescent idiopathic scoliosis (AIS). This systematic review and meta-analysis compare (1) Cobb angle correction, (2) complication and reoperation rate, (3) pulmonary function, (4) number of fused segments, and 5) patient-reported outcome measures (PROMs) in both groups. Methods: Electronic databases were searched to identify studies that met the following inclusion criteria: comparative studies (level 3 or above), severe thoracic curves (≥ 70°), age ≤ 16, AIS aetiology, Lenke 1-4 curves and follow-up ≥ 1 year for ≥ 95% of patient population. Literature was graded for quality and bias using GRADE and MINORS criteria. Results: Eight studies were included, defined by GRADE as low or moderate level evidence. Three studies showed superior curve correction in the APSF group; however, the meta-analysis showed no significant difference in curve correction between groups (95% CI - 3.45-12.96, P = 0.26). There were more complications in the APSF group, without statistical significance (95% CI 0.53-3.39, P = 0.54; I 2 = 0%, P = 0.78). There were no re-operations in either group. Two studies reported pulmonary function; one showed better function in the APSF group, the other better function in the PSF group. One study showed fewer fused segments in the APSF group, however, no significance was observed in the meta-analysis (95%CI - 1.65-0.31, P = 0.18). Three studies reported PROMs with no differences reported between groups. Conclusions: APSF and PSF have been found to have comparable results. The present evidence cannot support recommendations for guidelines on future practice with regards to effect on curve correction, complications, re-operations, pulmonary function or PROMs. Level of evidence: Level III, Systematic review of Level-III studies.

An inducible rodent glaucoma model that exhibits gradual sustained increase in intraocular pressure with distinct inner retina and optic nerve inflammation.

Glaucoma is a chronic and progressive neurodegenerative disease of the optic nerve resulting in loss of retinal ganglion cells (RGCs) and vision. The most prominent glaucoma risk factor is increased intraocular pressure (IOP), and most models focus on reproducing this aspect to study disease mechanisms and targets. Yet, current models result in IOP profiles that often do not resemble clinical glaucoma. Here we introduce a new model that results in a gradual and sustained IOP increase over time. This approach modifies a circumlimbal suture method, taking care to make the sutures 'snug' instead of tight, without inducing an initial IOP spike. This approach did not immediately affect IOPs, but generated gradual ocular hypertension (gOHT) as the sutures tighten over time, in comparison to loosely sutured control eyes (CON), resulting in an average 12.6 mmHg increase in IOP at 17 weeks (p < 0.001). Corresponding characterization revealed relevant retinal and optic nerve pathology, such as thinning of the retinal nerve fiber layer, decreased optokinetic response, RGC loss, and optic nerve head remodeling. Yet, angles remained open, with no evidence of inflammation. Corresponding biochemical profiling indicated significant increases in TGF-ß2 and 3, and IL-1 family cytokines in gOHT optic nerve tissues compared to CON, with accompanying microglial reactivity, consistent with active tissue injury and repair mechanisms. Remarkably, this signature was absent from optic nerves following acute ocular hypertension (aOHT) associated with intentionally tightened sutures, although the resulting RGC loss was similar in both methods. These results suggest that the pattern of IOP change has an important impact on underlying pathophysiology.

F-18 FDG PET-CT for response evaluation in head and neck malignancy: Experience from a tertiary level hospital in south India.

BACKGROUND: Head and neck squamous cell carcinoma (HNSCC) accounts for 90% of head and neck cancers. There has been no established qualitative system of interpretation for therapy response assessment using PET-CT for HNSCC. AIM: To assess response evaluation of nodal status in post-treatment PET-CT scans in HNSCC using a 5-point Likert scale (Deauville score [DS]). METHODS AND RESULTS: Retro-prospective analysis was performed of the nodal status of pre and post-RT PET-CT in patients diagnosed with HNSCC (n = 43) from May 2013 to March 2018. All eligible patients underwent a pre-RT PET-CT scan before the start of RT. Another post-RT PET-CT scan was performed 12 weeks after the completion of RT. The median time from completion of radiotherapy (RT) to post-RT PET-CT was 92 days; 80% of the patients had their post-RT PET-CT scan between 77 and 147 days after therapy. Of 43 patients (M/33, F/10, age range 18 to 80 years (median 54 years) selected for the study, good concordance was noted between DS and clinical response in these patients. The change in SUV from pre-RT PET to post-RT PET was analyzed using a paired t-test. The P-value was found to be statistically significant while comparing pre and post-RT SUVmax levels showing that RT had significantly reduced the SUVmax levels of the nodes in DS 2-3 groups whereas the number of patients was too small to allow a reliable calculation in DS 4-5 groups. It was found that 36/39 patients with DS 1-3 had no nodal recurrence showing a high NPV of 92.3%. Of the four patients with DS 4-5, all had active disease showing PPV of 100%. Applying Fisher's exact test, the P-value was found to be .004. CONCLUSION: DS seems to satisfy the requirements for a simple qualitative method of interpreting PET scans and for identifying patients requiring neck dissection. Consensus regarding qualitative assessment would facilitate standardization of PET reporting in clinical practice and enable comparative multicentric studies.