Genitofemoral peripheral nerve stimulator implantation for refractory groin pain: a case report.

PURPOSE: Genitofemoral neuralgia (GFN) is a chronic pain condition that may be refractory to commonly employed treatment modalities. Implantation of a peripheral nerve stimulator (PNS) may provide significant pain relief; however, few reports have described placement of and response to a GFN PNS implant. CLINICAL FEATURES: We implanted a StimRouter® PNS in a 42-yr-old male with severe GFN that did not respond to pharmacologic and interventional pain management modalities and impaired all aspects of his function and quality of life. The often-challenging sonographic visualization of the genitofemoral nerve was aided by intraprocedural sensory mapping using a stimulating probe. Preoperatively, the patient's average pain was rated as 7 on a 0 to 10 numeric rating scale. Following the procedure, the patient experienced over 90% pain relief after one week. At one and five months post implantation, the patient's average pain scores were 1 and 0.5, respectively. The patient also reported substantial improvement in the physical component scores on the 12-Item Short Form Survey (SF-12), which remained similar at the five-month follow-up (from 26.1 preop to 57.2 at one month and 49.7 at five months). CONCLUSIONS: Peripheral nerve stimulator implantation may be a promising intervention when other analgesic modalities fail to manage refractory GFN. Further research to verify the effectiveness of this intervention and evaluate for appropriate integration in patient care is required.

RéSUMé: OBJECTIF: La névralgie génito-crurale (NGC) est une douleur chronique pouvant être réfractaire aux modalités de traitement couramment utilisées. L'implantation d'un stimulateur nerveux périphérique (SNP) peut apporter un soulagement significatif de la douleur. Cependant, peu de présentations de cas ont décrit la mise en place et la réponse à l'implantation d'un SNP pour soulager une névralgie génito-crurale. CARACTéRISTIQUES CLINIQUES: Nous avons implanté un SNP StimRouter® chez un homme de 42 ans atteint d'une NGC grave qui ne répondait pas aux modalités pharmacologiques et interventionnelles de prise en charge de la douleur et entravait tous les aspects fonctionnels et de qualité de vie. La visualisation échographique souvent difficile du nerf génito-crural a été facilitée grâce à une cartographie sensorielle intraprocédurale, réalisée à l'aide d'une sonde de stimulation. Avant la procédure, la douleur moyenne du patient a été évaluée à 7 sur une échelle d'évaluation numérique de 0 à 10. Suite à l'intervention, le patient a ressenti un soulagement de la douleur de plus de 90 % après une semaine. À un et à cinq mois suivant l'implantation, les scores moyens de douleur du patient étaient de 1 et 0,5, respectivement. Le patient a également rapporté une amélioration substantielle des scores de la composante physique du questionnaire SF-12, scores qui sont restés similaires au suivi à cinq mois (de 26,1 avant l'intervention à 57,2 à un mois et 49,7 à cinq mois). CONCLUSION: L'implantation d'un stimulateur nerveux périphérique pourrait être une intervention prometteuse lorsque d'autres modalités analgésiques ne parviennent pas à prendre en charge une névralgie génito-crurale réfractaire. D'autres recherches sont nécessaires pour vérifier l'efficacité de cette intervention et évaluer son intégration appropriée dans les soins aux patients.

Efficacy and safety of basic fibroblast growth factor (bFGF) related decapeptide solution plus Tacrolimus 0.1% ointment versus Tacrolimus 0.1% ointment in the treatment of stable vitiligo.

Vitiligo is common acquired pigmentary disorder affecting skin of 1% of the world population, India 3% to 8% incidences approximately. Treatment is tough challenge. The combination treatments have proven beneficial due to different mechanisms. There is need to find drug targeting different mechanisms of action. Test medicine is decapeptide derived from basic Fibroblast Growth Factor (bFGF) treating vitiligo. The current study was to compare efficacy and safety of BFGF related decapeptide solution plus Tacrolimus 0.1% (M + T) Ointment versus Tacrolimus monotherapy 0.1% (T) Ointment in patients with stable vitiligo. The randomized, open label, comparative, prospective, multicentre study in patients with stable vitiligo was conducted. The primary endpoint was improvement in extent of repigmentation in target lesion after 12 months of treatment from baseline. The secondary endpoints were extent of repigmentation at end of 6 months, patient global assessment (PGA) and safety at end of 6 months. This shows interim analysis results. Total 94 patients were randomized to M + T (n = 40) and T (n = 44), 10 patients were lost to follow up. Extent of repigmentation (>50%) was significantly greater at end of 8 weeks in M + T group 22.5% (p ≤ .05) while 6.8% in T group. In grade of repigmentation, significant difference (p ≤ .05) was observed, M + T had better grade. PGA was significantly greater (p ≤ .05) in M + T-group than T. All these parameters showed significant improvement in M + T-group than group T at end of 6 months. No adverse events were reported during the study. It is an interim analysis report so complete data is not available for analysis. Addition of bFGF related decapeptide solution to Tacrolimus gave better results than Tacrolimus alone therapy. It also has a favorable safety profile and was well tolerated.

The Incidence of Central Line-Associated Bacteremia After the Introduction of Midline Catheters in a Ventilator Unit Population.

HYPOTHESIS: Our objective was to evaluate whether the use of midline venous catheters in place of central line venous catheters, when appropriate, decreased the overall incidence of central line-associated bacteremia in a ventilator unit. METHODS: The time interval between February 2012 and February 2013 was divided into 2 periods. Group A was the first half of the year, before the introduction of midline catheters, and group B was the second half of the year, 6 months after their introduction. Central line-associated bloodstream infection (CLABSI) was calculated using the equation: (total number of CLABSI/total number of catheter days) × 1000. The Z test was used for proportions between independent groups to compare the significance in the difference in CLABSI between groups A and B. RESULTS: There was a significant decrease in the total number of catheter days on the ventilator unit in group A from 2408 catheter days in 1 year (August 1, 2011, to July 31, 2012) before the introduction of midline catheters to 1521 catheter days in group B in the following year (November 1, 2012, to October 31, 2013; P < 0.05 for both groups). CONCLUSIONS: Midline catheters in place of central lines decrease the rate of CLABSI in a ventilator unit. In addition, no bloodstream infections were associated with midline catheters.

Prevalence of depression and associated risk factors among persons with type-2 diabetes mellitus without a prior psychiatric history: a cross-sectional study in clinical settings in urban Nepal.

BACKGROUND: Diabetes is a growing health problem in South Asia. Despite an increasing number of studies exploring causal pathways between diabetes and depression in high-income countries (HIC), the pathway between the two disorders has received limited attention in low and middle-income countries (LMIC). The aim of this study is to investigate the potential pathway of diabetes contributing to depression, to assess the prevalence of depression, and to evaluate the association of depression severity with diabetes severity. This study uses a clinical sample of persons living with diabetes sequelae without a prior psychiatric history in urban Nepal. METHODS: A cross-sectional study was conducted among 385 persons living with type-2 diabetes attending tertiary centers in Kathmandu, Nepal. Patients with at least three months of diagnosed diabetes and no prior depression diagnosis or family history of depression were recruited randomly using serial selection from outpatient medicine and endocrine departments. Blood pressure, anthropometrics (height, weight, waist and hip circumference) and glycated hemoglobin (HbA1c) were measured at the time of interview. Depression was measured using the validated Nepali version of the Beck Depression Inventory (BDI-Ia). RESULTS: The proportion of respondents with depression was 40.3%. Using multivariable analyses, a 1-unit (%) increase in HbA1c was associated with a 2-point increase in BDI score. Erectile dysfunction was associated with a 5-point increase in BDI-Ia. A 10 mmHg increase in blood pressure (both systolic and diastolic) was associated with a 1.4-point increase in BDI-Ia. Other associated variables included waist-hip-ratio (9-point BDI-Ia increase), at least one diabetic complication (1-point BDI-Ia increase), treatment non-adherence (1-point BDI-Ia increase), insulin use (2-point BDI-Ia increase), living in a nuclear family (2-point BDI-Ia increase), and lack of family history of diabetes (1-point BDI-Ia increase). Higher monthly income was associated with increased depression severity (3-point BDI-Ia increase per 100,000 rupees, equivalent US$1000). CONCLUSIONS: Depression is associated with indicators of more severe diabetes disease status in Nepal. The association of depression with diabetes severity and sequelae provide initial support for a causal pathway from diabetes to depression. Integration of mental health services in primary care will be important to combat development of depression among persons living with diabetes.

Comparison of Acute Physiology and Chronic Health Evaluation II, Bedside Index for Severity in Acute Pancreatitis and Modified Computed Tomography Severity Index Scores in Predicting the Outcome in Acute Pancreatitis in a Tertiary Care Centre in Nepal.

BACKGROUND: It is important to identify the severity of acute pancreatitis in the early course of the disease. METHODS: This prospective observational study included 83 patients with acute pancreatitis. The Acute Physiology and Chronic Health Evaluation II and the Bedside Index for Severity in Acute Pancreatitis scores were assessed within 24 hours of admission, and the modified computed tomography severity index score was calculated in those patients who underwent contrast enhanced computed tomography.  The sensitivity, specificity, positive predictive value, and negative predictive value of scoring systems were calculated. The area under the curve was calculated for assessing the prognostic value of scoring systems. RESULTS: The modified computed tomography severity index was the most accurate score in predicting severity and local complications with an area under the curve of 0.92 and 0.91, respectively. The Bedside Index for Severity in Acute Pancreatitis score was the most accurate in predicting organ failure and the need for intensive care unit admission with an area under the curve of 0.70 and 0.78 respectively. CONCLUSIONS: The results of this study demonstrate that modified computed tomography severity index and Bedside Index for Severity in Acute Pancreatitis scores had overall better predictive value than the Acute Physiology and Chronic Health Evaluation II score in predicting severity, organ failure, local complication, and need for intensive care unit admission.

Efficacy and Safety Comparison of Basic Fibroblast Growth Factor-Related Decapeptide 0.1% Solution (bFGFrP) Plus Oral PUVA Combination Therapy with Oral PUVA Monotherapy in the Treatment of Vitiligo.

Background: Phototherapy in its different forms, is mainstay of vitiligo management. Combining treatment modalities like topical calcipotriol (for quicker, more intense repigmentation), Low dose azathioprine with PUVA have proven to be beneficial in management of vitiligo due to different mechanisms of repigmentation and their synergistic effects. Topical bFGF-related decapeptide (bFGFrP) application followed by sun exposure/ UVA phototherapy yields effective repigmentation. bFGFrP has shown to aid the targeted phototherapy in smaller lesions and its combinations with other treatment modalities have been very promising. However, there is paucity of studies on combination treatments; especially oral PUVA along with bFGFrP. This study was aimed at evaluating safety and efficacy of combination of bFGFrP with Oral PUVA in vitiligo (larger body surface area 20% or more). Materials and Methods: Phase IV, randomized, multicentre study (N = 120) in adult patients with stable vitiligo of 6 months treatment period with monthly follow up visits. Psoralen (Tab. Melanocyl) dosage 0.6 mg/kg orally 2 h before exposure to UVA phototherapy. Oral PUVA therapy, initially, at an irradiation dose 4 J/cm2 (PUVA group), followed by increments 0.5 J/cm2 every four sittings if tolerated for twice weekly. Primary end point was improvement in extent of repigmentation (EOR) in target lesion (at least 2 cm × 2 cm in greatest dimension, without leukotrichia), while secondary endpoints were improvement in patient global assessment (PGA) and safety at end of 6 months of treatment period in bFGFrP + oral PUVA combination group and Oral PUVA monotherapy group. Results: End of 6 months, significantly greater EOR >50%) was achieved in 61.8% (34 patients, n = 55) from combination group while 30.2% (16 patients, n = 53) from the oral PUVA monotherapy group (n = 53). Regarding Grade of repigmentation (GOR), complete repigmentation was observed 5.5% (3 patients, n = 55) in combination group whereas no patient showed complete repigmentation in monotherapy group (p ≤ 0.05), PGA showed significant overall improvement in combination group (p ≤ 0.05); 6 patients (10.9%) from combination group Vs one (1.9%) showed complete improvement. During treatment period, there were no reported adverse events. Conclusions: Addition of bFGFrP to oral PUVA therapy resulted in intense and faster induction of repigmentation than oral PUVA monotherapy with favorable safety profile.

Liver Cirrhosis among Young Adults Admitted to the Department of Gastroenterology in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Cirrhosis in young adults is an important health problem worldwide and is a common disease. Patients usually present late in a decompensated state with varied complications. However, national data on the exact burden of the disease is lacking. The aim of this study was to find out the prevalence of liver cirrhosis among young adults admitted to the Department of Gastroenterology in a tertiary care centre. Methods: A descriptive cross-sectional study was done among patients admitted to the Department of Gastroenterology in a tertiary care centre between 25 November 2021 to 30 November 2022 after receiving ethical approval from the Institutional Review Committee [Reference number: 227(6-11)E2-078/079]. Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated. Results: Among 989 patients, liver cirrhosis in young adults was seen in 200 (20.22%) (18.12-22.32, 95% Confidence Interval). Chronic alcohol use was the primary cause of cirrhosis seen in 164 (82%) cases. The most typical presenting symptom was abdominal distension seen in 187 (93.50%) patients. The most frequent complication was ascites seen in 184 (92%) patients. The most frequent endoscopic finding was gastro-oesophagal varices seen in 180 (90%) patients. There were 145 (72.50%) men and 55 (27.50%) women. Conclusions: The prevalence of liver cirrhosis in young adults was found to be lower than the other studies done in similar settings. Keywords: ascites; liver cirrhosis; prevalence.

Antimitochondrial antibody-negative primary biliary cirrhosis with secondary Sjogren syndrome: a case report.

Introduction and importance: Primary biliary cholangitis (PBC) is a rare immune-mediated liver disease characterized by the destruction of intrahepatic bile ducts and a positive antimitochondrial antibody (AMA), which is considered a serological hallmark for the diagnosis. Rarely, AMA can be absent/nondetectable in a few cases and is referred to as 'AMA-negative'. Case presentation: The authors present such an uncommon case of AMA-negative PBC in a 39-year-female with Sjogren's syndrome who presented with fatigue, pruritus, and dry eyes. Clinical discussion: Previously published studies state that approximately only about 5% of patients with PBC are 'AMA-negative'. For patients negative for AMA, the diagnosis has to be based on typical pathological features of this disease. Once a diagnosis of PBC is established, regardless of whether it is positive or negative for AMAs, ursodeoxycholic acid is a widely accepted treatment. Conclusion: The presence/absence of AMAs is associated with similar clinical, biochemical, and histopathological characteristics in PBC. The identification of AMAs alone should not impact the diagnosis or treatment of PBC.

Hepatic Encephalopathy Induced Transient Cortical Blindness.

Hepatic encephalopathy describes a spectrum of potentially reversible neuropsychiatric abnormalities seen in a patient with severe liver dysfunction with porto-systemic shunting. Cortical blindness can be a rare presentation of hepatic encephalopathy and can even precede the onset of altered sensorium. We report a case of 57 years female with chronic liver disease who presented with bilateral loss of vision, with no focal neurological deficits. From clinical and laboratory examination, a diagnosis of hepatic encephalopathy with cortical blindness was proposed. Her visual disturbances gradually improved with the treatment of hepatic encephalopathy. Keywords: Cortical blindness; end stage liver disease; hepatic encephalopathy; papilledema.

Trichobezoar presenting with chief complaints of chest pain, weight loss, and gastrointestinal bleeding.

Abdominal pain is a frequent presenting complaint in pediatric patients seeking acute medical care. We report the case of an adolescent female who presented with nonspecific complaints of chest pain, faintness, and weight loss and whose diagnosis was determined only after the disclosure of trichophagia.

Ameliorating effect of N-acetylcysteine and curcumin on pesticide-induced oxidative DNA damage in human peripheral blood mononuclear cells.

Endosulfan, malathion, and phosphamidon are widely used pesticides. Subchronic exposure to these contaminants commonly affects the central nervous system, immune, gastrointestinal, renal, and reproductive system. There effects have been attributed to increased oxidative stress. This study was conducted to examine the role of oxidative stress in genotoxicity following pesticide exposure using peripheral blood mononuclear cells (PBMC) in vitro. Further possible attenuation of genotoxicity was studied using N-acetylcysteine (NAC) and curcumin as known modulators of oxidative stress. Cultured mononuclear cells was isolated from peripheral blood of healthy volunteers, and exposed to varying concentrations of different pesticides: endosulfan, malathion, and phosphamidon for 6, 12, and 24 h. Lipid peroxidation was assessed by cellular malondialdehyde (MDA) level and DNA damage was quantified by measuring 8-hydroxy-2'-deoxyguanosine (8-OH-dG) using ELISA. Both MDA and 8-OH-dG were significantly increased in a dose-dependent manner following treatment with these pesticides. There was a significant decrease in MDA and 8-OH-dG levels in PBMC when co-treated with NAC or/and curcumin as compared to pesticide alone. These results indicate that pesticide-induced oxidative stress is probably responsible for the DNA damage, and NAC or curcumin attenuate this effect by counteracting the oxidative stress.

Detection of Colonic Polyps During Colonoscopy in a Tertiary Care Center of Nepal.

BACKGROUND: Colorectal cancer is the third leading cause of cancer death in the world. Most colon cancer develop from the polyps. Data on the prevalence of colorectal polyps in Nepal is lacking. The objective was to determine the prevalence of colorectal polyps, site of occurrence and adenomas among various age groups. All polyps after removal by polypectomy was sent for histopathological examination. METHODS: Study was done in 1027 consecutive patients who underwent colonoscopy in the pre-specified time after excluding patients with colorectal cancer, Inflammatory Bowel Disease and polyposis syndromes. RESULTS: Among 1027 patients, the mean age was 45 years. 292 (28.43%) were below 40 years, whereas, 735 (71.57%) were above 40 years. Polyps were detected in 12.95% of overall patients and in 9.73% of patients over age 40. The most common location of polyps was rectum (46.62%). 43.61% were adenomatous polyps, 11.28% were hyperplastic polyps, 18.05% were juvenile polyps, 22.56% were inflammatory polyps and 1.50% were malignant adenocarcinoma. Polyp detection rate was 12.95%, whereas adenoma detection rate was 5.84%. 46.55% had advanced adenomas. A positive correlation between the size of polyp and adenomatous variety was found [Chi-square value ?2 = 8.42 (>3.841), p value <0.05]. Prevalence of adenomatous polyps was significantly higher above the age of 40 [Chi-square value ?2 = 11.53 (>3.841), p value<0.05].  Conclusions: The prevalence of polyp increases with age. With increasing age and size of polyp, the prevalence of adenomatous polyp increases significantly. One out of every eight people over 40 years had a colonic polyp.

Association of glutathione S-transferase M1 and T1 gene polymorphism with oxidative stress in diabetic and nondiabetic chronic kidney disease.

BACKGROUND AND OBJECTIVE: Glutathione S-transferases (GSTs) belong to a family of ubiquitous and multifunctional enzymes that work as one of the endogenous antioxidants in our body. This study was designed to look into the association of GST polymorphism with oxidative stress in both diabetic and nondiabetic chronic kidney disease (CKD). DESIGN AND METHODS: Three groups of patients (50 in each): diabetics without CKD (DM), diabetic CKD (DM-CKD), and nondiabetic CKD (NDM-CKD) and 50 age- and sex-matched healthy controls were recruited. Genotyping was done for GSTM1 and GSTT1 genes using a multiplex polymerase chain reaction. Serum GST and malondialdehyde (MDA) as a marker of oxidative stress were measured spectrophotometrically. RESULTS: Based on genotyping, subjects were categorized as GSTM1+/GSTT1+, GSTM1-/GSTT1+, GSTM1+/GSTT1-, and GSTM1-/GSTT1-. Serum GST levels were lower among subjects with deletion in one/both GST genes, whereas MDA levels were found to be correspondingly raised. A negative correlation for MDA versus GST levels was observed among genotypes with one/both gene deletions. Presence of GSTM1+/GSTT1- and GSTM1-/GSTT1- was significantly higher among patients with CKD in both diabetics and nondiabetics. INTERPRETATIONS AND CONCLUSIONS: GSTM1 and GSTT1 deletions singly or together were associated with lower GST levels and higher oxidative stress in both diabetic and nondiabetic CKD. Interestingly, GSTT1 deletion appears to be associated with both diabetic and nondiabetic CKD irrespective of the GSTM1 status.

Validation of the MDRF-Indian Diabetes Risk Score (IDRS) in another south Indian population through the Boloor Diabetes Study (BDS).

OBJECTIVE: To validate the MDRF-Indian Diabetes Risk Score (IDRS) in a south Indian population in coastal Karnataka. METHODS: The study was conducted at Boloor locality in Mangalore on adults aged 20 years or more. The study group comprised 551 participants (68.9% response rate). The OGTT was performed using 75 gms of glucose. The MDRF-IDRS was calculated using age, family history of diabetes, physical activity and waist measurement. ROC curves were constructed to identify the optimum value (> or = 60%) of IDRS for determining diabetes as diagnosed using WHO consulting group criteria. RESULTS: We found that 71 of the study individuals were known diabetic subjects (KD) while 45 subjects were diagnosed to have newly diagnosed diabetes (NDD). An IDRS score of > or =60 had the best sensitivity (62.2%) and specificity of (73.7%) for detecting undiagnosed diabetes in this community. CONCLUSION: Our study confirms and validates the MDRF-IDRS as being a valid simple and reliable screening tool to identify undiagnosed diabetes in the community. The MDRF-IDRS score > or =60 had the highest sensitivity and specificity to identify undiagnosed diabetes.

Prevalence of metabolic syndrome (METS) using IDF 2005 guidelines in a semi urban south Indian (Boloor Diabetes Study) population of Mangalore.

OBJECTIVE: To identify metabolic syndrome (MetS) prevalence using International Diabetes Federation (IDF) 2005 guidelines in a semi urban south Indian (Boloor Diabetes Study) population of Mangalore. METHODS: Population of randomly selected adults > or =20 years living in Boloor locality who were available for the house to house survey were assessed for the following: anthropometric variables; blood pressure; fasting blood glucose and lipid profile. Among 800 responders; 300 men, 500 women, 551 were examined (68.8%). Fasting plasma glucose as well fasting lipid profile could be done for 451 (147 men, 304 women) 81.85%; Data was analysed for prevalence of MetS and its individual components. Diagnosis of MetS was based on IDF 2005 criteria for Asian men and women. Intergroup comparisons were performed using student 't' test and Chi-square test. RESULTS: MetS was prevalent in 134 of 451 (29.7%); men 39 (26.5%) and women 95 (31.2%). Prevalence of individual components of MetS were as follows: increased waist circumference, (common component) present in all; elevated TG in 38.8%; low HDL-C in 59.7%; increased FPG in 57.4%; elevated SBP in 80.5% and DBP in 56.7%; body mass index (BMI) > or =25 kg/sq.m (obesity) in 58.9% Barring increased waist circumference which is the essential criteria for diagnosis of Mets, Systolic hypertension emerged as the most frequent component in the population followed by low HDL-C and elevated FPG. Elevated TG was less prevalent in this population. CONCLUSION: Prevalence of MetS in this semi urban population (Boloor) of Mangalore compares with MetS prevalence identified in cross sectional studies in India. Prevention and treatment of the predictive factors: dyslipidemias, hyperglycaemia, hypertension, together with enhanced physical activity may together reduce the prevalence of MetS.

Maternal and cord blood levels of aldrin and dieldrin in Delhi population.

Aldrin and dieldrin, structurally similar organochlorine pesticides belong to cyclodiene family and were widely used for agriculture and public health program in India. Although the manufacturing, use and import of aldrin and dieldrin have been banned in India since 2003, these pesticides are still persistent in environment and may be associated with adverse neurological and reproductive effects. The aim of this study is to assess the recent exposure level of aldrin and dieldrin and their placental transfer to fetus in normal healthy full-term pregnant women belonging to north Indian population undergoing normal delivery at Obstetrics and Gynecology department of UCMS and GTB hospital, Delhi. Quantitative analysis of aldrin and dieldrin residues in maternal and cord blood samples were carried out by gas chromatography system equipped with electron capture detector. The results of our study clearly revealed that maternal and cord blood levels of aldrin and dieldrin of pregnant women are age and dietary habit dependent. The aldrin level in maternal blood and dieldrin level in cord blood are higher in women in the age group 25-30 years than in women in age group of 19-24 years. Similarly, aldrin level in maternal blood is significantly higher in women with non-vegetarian dietary habit than in women with vegetarian dietary habit. No significant association is found for maternal and cord blood level. The results of the present study clearly demonstrate prenatal uptake of aldrin and dieldrin and provide recent information on the subsequent transplacental transfer.

Prevalence of Covert Hepatic Encephalopathy in A Tertiary Care Centre.

INTRODUCTION: Among patients with Hepatic Encephalopathy, prevalence of Minimal HE varies between 30-50%. Identifying patients with MHE has been shown to improve with medications and delay development of Overt HE, however only limited clinicians screen for MHE in patients due to time consuming neuropsychological and neurophysiological tests. The Number Connection Test is an easy way to evaluate patients to diagnose MHE. The aim of this study is to find out the prevalence of covert hepatic encephalopathy. METHODS: The descriptive cross-sectional study was done to find out the prevalence of covert hepatic encephalopathy among patients with chronic liver disease. To diagnose Covert HE which included MHE as well, NCT was used in Devanagari script. RESULTS: The prevalence of covert hepatic encephalopathy is found to be 56 (58.3%) at 90% confidence interval (58.23-58.37%). A total of 96 patients (71.9% male) were diagnosed as HE, with mean age of 49.6+11.8 years. The cause of CLD in 85 (88.5%) of these patients was alcohol, of which 76 (79.2%) consumed locally brewed alcohol. Of these 96 patients with HE, only 40 (41.7%) had overt HE. Among all these, maximum patients had MHE (37.5%). CONCLUSIONS: Our study showed that although the prevalence of minimal HE is quite high among cirrhotics, they are usually missed in clinical practice due to absence of symptoms. Active screening with easy-to-administer tests, like Number Connection tests, can help identify patients with minimal HE and hence treat them early.

Comparative Study of Slow Infusion versus Bolus Doses of Albumin and Furosemide Infusion to Mobilize Refractory Ascites in Decompensated Chronic Liver Disease.

BACKGROUND: Combined use of furosemide with albumin is an approved therapy to overcome diuretic resistance in treatment of ascites in decompensated chronic liver disease. Bolus dosing of diuretics has its own limitations due to pre-existing hypotension, post diuretic sodium retention and braking phenomenon. Slow albumin and furosemide Infusion has been shown to mobilize large ascites with improved diuresis and hemodynamic stability in decompensated chronic liver disease. This study was undertaken to compare efficacy and safety of infusion therapy vs bolus therapy in term the management of refractory ascites. METHODS: Decompensated chronic liver disease patients with refractory ascites were randomly assigned into two groups of 15 each - Bolus therapy (intravenous albumin and furosemide as boluses) and Infusion therapy (furosemide infusion at 2mg/hour and albumin at 2g/hour for three days). Diuresis, natriuresis, change in abdominal girth and body weight, and hemodynamic stability (change in SBP) were compared between the two groups. RESULTS: Infusion therapy, as compared to bolus therapy, showed a significantly better diuresis (mean urinary output increment 483ml vs 243ml, p <0.001), natriuresis (mean urinary sodium excretion increment 35.2 mEq/L vs 16.6 mEq/L, p = 0.004),decrease in abdominal circumference (6.1cm vs 3.0cm, p<0.001) and decrease in body weight (5.53 Kg vs 2.86 Kg, p < 0.001). The complications of renal impairment were also lower in the Infusion group. CONCLUSION: Infusion of furosemide and albumin is a potential safer and effective therapeutic option in the management of refractory ascites with better natriuresis, higher urine output, and higher decrement in abdominal circumference and body weight, and lesser side effects.

Symptomatic Hyponatremia following Bowel Preparation for Colonoscopy: A Case Report.

Colonoscopy is considered a gold standard tool for the diagnostic evaluation of colorectal diseases. Bowel preparation, a pre-requisite for colonoscopy, usually involves ingestion of purgatives for the cleansing of the bowel so that visualization is not obscured during the procedure. Commonly used preparations are sodium phosphate-based solutions, sodium picosulphate and polyethylene glycol. The use of such preparations is associated with electrolyte disturbances, commonly hyponatremia. Hyponatremia is usually seen with sodium phosphate based solutions and is rare with polyethylene glycol. Symptomatic hyponatremia, however, is rare following bowel preparation and is attributable to other factors as well, such as the age of patient, non-osmotic release of antidiuretic hormone and the procedure itself. In this report, we discuss a case of severe symptomatic hyponatremia observed in a 71-year-old gentleman who underwent polyethylene glycol based bowel preparation for colonoscopy.

Machine Learning Confirms Nonlinear Relationship between Severity of Peripheral Arterial Disease, Functional Limitation and Symptom Severity.

BACKGROUND: Peripheral arterial disease (PAD) involves arterial blockages in the body, except those serving the heart and brain. We explore the relationship of functional limitation and PAD symptoms obtained from a quality-of-life questionnaire about the severity of the disease. We used a supervised artificial intelligence-based method of data analyses known as machine learning (ML) to demonstrate a nonlinear relationship between symptoms and functional limitation amongst patients with and without PAD. OBJECTIVES: This paper will demonstrate the use of machine learning to explore the relationship between functional limitation and symptom severity to PAD severity. METHODS: We performed supervised machine learning and graphical analysis, analyzing 703 patients from an administrative database with data comprising the toe-brachial index (TBI), baseline demographics and symptom score(s) derived from a modified vascular quality-of-life questionnaire, calf circumference in centimeters and a six-minute walk (distance in meters). RESULTS: Graphical analysis upon categorizing patients into critical limb ischemia (CLI), severe PAD, moderate PAD and no PAD demonstrated a decrease in walking distance as symptoms worsened and the relationship appeared nonlinear. A supervised ML ensemble (random forest, neural network, generalized linear model) found symptom score, calf circumference (cm), age in years, and six-minute walk (distance in meters) to be important variables to predict PAD. Graphical analysis of a six-minute walk distance against each of the other variables categorized by PAD status showed nonlinear relationships. For low symptom scores, a six-minute walk test (6MWT) demonstrated high specificity for PAD. CONCLUSIONS: PAD patients with the greatest functional limitation may sometimes be asymptomatic. Patients without PAD show no relationship between functional limitation and symptoms. Machine learning allows exploration of nonlinear relationships. A simple linear model alone would have overlooked or considered such a nonlinear relationship unimportant.