BACKGROUND Recent investigations noted noninferiority in short-course antimicrobial treatments following source control in abdominal infections. We set out to investigate noninferiority of a short and fixed (24 hours) antibiotic administration compared to extended treatment after source control in complicated appendicitis in a prospective single-center open-label randomized controlled trial. METHODS After Institutional Review Board (IRB) approval, all consecutive adult patients (age, ≥ 18 years) with complicated appendicitis including gangrenous appendicitis, perforated appendicitis, and appendicitis with periappendicular abscess between May 2016 and February 2018 were randomly allocated to antibacterial therapy limited to 24 hours (short) vs. >24 hours (extended) administration after appendectomy. Primary outcomes included composite postoperative complications and Comprehensive Complication Index (CCI). Secondary outcome was hospital length of stay (HLOS). Follow-up analysis at 1 month was conducted per intention and per protocol. RESULTS A total of 80 patients were enrolled with 39 and 41 cases allocated to the short and the extended therapy group, respectively. Demographic profile and disease severity was similar between the study groups. Overall rate of complications was 17.9% and 29.3% in the short and extended group, respectively (p = 0.23). Mean CCI did not differ between the study groups (p = 0.29). Hospital length of stay was significantly reduced in the short therapy group (61 ± 34 hours vs. 81 ± 40 hours, p = 0.005). CONCLUSION In the current prospective randomized investigation, the short (24 hours) antibiotic administration following appendectomy did not result in a worse primary outcome in complicated appendicitis. The short interval administration resulted in a significant reduction in HLOS with a major cost-saving and antibacterial stewardship perspective. LEVEL OF EVIDENCE Therapeutic Level IV.
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AbstractBackground.The expression of depressive symptoms in older people with cancer is heterogeneous because of specific features of age or cancer comorbidity. We aimed to identify depressive symptom profiles in this population and describe the associated features including survival.Materials and Methods.Patients ≥70 years who were referred to geriatric oncology clinics were prospectively included in the ELCAPA study. In this subanalysis, depressive symptoms were used as indicators in a latent class analysis. Multinomial multivariable logistic regression and Cox models examined the association of each class with baseline characteristics and mortality.Results.For the 847 complete‐case patients included (median age, 79 years; interquartile range, 76–84; women, 47.9%), we identified five depressive symptom classes: "no depression/somatic only" (38.8%), "no depression/pauci‐symptomatic" (26.4%), "severe depression" (20%), "mild depression" (11.8%), and "demoralization" (3%). Compared with the no depression/pauci‐symptomatic class, the no depression/somatic only and severe depression classes were characterized by more frequent comorbidities with poorer functional status and higher levels of inflammation. "Severe" and "mild" depression classes also featured poorer nutritional status, more medications, and more frequent falls. Severe depression was associated with poor social support, inpatient status, and increased risk of mortality at 1 year (adjusted hazard ratio, 1.62, 95% confidence interval, 1.06–2.48) and 3 years (adjusted hazard ratio, 1.49; 95% confidence interval, 1.06–2.10).Conclusion.A data‐driven approach based on depressive symptoms identified five different depressive symptom profiles, including demoralization, in older patients with cancer. Severe depression was independently and substantially associated with poor survival.Implications for Practice.Older patients with cancer present with distinct profiles of depressive symptomatology, including different severity levels of depression and the demoralization syndrome. Clinicians should use a systematic assessment of depressive symptoms to adequately highlight these distinct profiles. Geriatric and oncological features are differently associated with these profiles. For instance, severe depression was associated with more frequent comorbidities with poorer functional, poor nutritional status, polypharmacy, frequent falls, inpatient status and poor social support. Also, severe depression was independently and substantially associated with poor survival so that the identification and management of depression should be considered a high priority in this population.
AbstractLessons Learned. TKM‐080301 showed a favorable toxicity profile at the studied dose.TKM‐080301 targeting PLK1 through small interfering RNA mechanism did not demonstrate improved overall survival in patients with advanced hepatocellular carcinoma compared with historical control. Preliminary antitumor activity as shown in this early‐phase study does not support further evaluation as a single agent.Background.Polo‐like kinase 1 (PLK1) is overexpressed in hepatocellular carcinoma (HCC). Knockdown of PLK1 expression by PLK1 small interfering RNA (siRNA) in an HCC cell line showed reduced expression in RNA‐induced silencing complex and a reduction in cell proliferation.Methods.A 3 + 3 dose escalation plus expansion cohort at the maximum tolerated dose (MTD) was implemented. Patients with HCC, Eastern Cooperative Oncology Group (ECOG) performance status ≤2, and Child‐Pugh score A received TKM‐080301 as an intravenous infusion once every week for 3 consecutive weeks, repeated every 28 days.Results.The study enrolled 43 patients. The starting dose of TKM‐080301 was 0.3 mg/kg, and MTD was declared at 0.75 mg/kg. Following the development of grade 4 thrombocytopenia in two subjects on the expansion cohort, the MTD was redefined at 0.6 mg/kg. Four patients did not have any evaluable postbaseline scan. Of the other 39 subjects who had received at least 0.3 mg/kg, 18 subjects (46.2%) had stable disease (SD) by independent RECIST 1.1 criteria. By Choi criteria, eight subjects (23.1%) had a partial response (PR). For 37 assessable subjects, with 2 subjects censored, median progression‐free survival (PFS) was 2.04 months. Median survival for the whole study population was 7.5 months.Conclusion.TKM‐080301 was generally well tolerated. In this early‐phase study, antitumor effect for TKM 080301 was limited. Further evaluation as a single agent in large randomized trials is not warranted.
AbstractTherapies for advanced non‐small cell lung cancer (NSCLC) continue to become more sophisticated. Chemotherapeutics are giving way to newer approaches such as immune checkpoint inhibitors and targeted therapies for greater efficacy and improved outcomes. Dabrafenib plus trametinib combination therapy was first approved for the treatment of metastatic melanoma harboring the BRAF V600‐mutation in 2014. In 2017, the U.S. Food and Drug Administration approved the combination for patients with NSCLC with the same mutation based on an ≈ 65% response rate and median progression‐free survival of 10–11 months. BRAF mutations are a high‐frequency event in melanoma (≈ 50%), whereas the overall incidence in lung cancer is ≈ 2%, but similar in number, because of the high incidence of the disease. As a new approach in NSCLC treatment, dabrafenib plus trametinib has a unique toxicity profile that is likely unfamiliar to care providers in thoracic and general oncology who have not used the combination to treat patients with melanoma. Common adverse events such as pyrexia, fatigue, and nausea, as well as a range of less frequent cutaneous, ocular, and hemorrhagic events, can be observed during treatment with dabrafenib plus trametinib. Previous experience in metastatic melanoma revealed that these events can be effectively managed to improve patient quality of life and reduce unnecessary drug discontinuation. The aim of this review is to summarize treatment guidelines, along with key insights obtained from previous clinical‐trial and real‐world experience in patients with metastatic melanoma, to properly manage toxicities associated with dabrafenib plus trametinib for NSCLC.Implications for Practice.The combination of dabrafenib plus trametinib has demonstrated substantial clinical activity in patients with BRAF V600E‐mutant non‐small cell lung cancer, leading to U.S. Food and Drug Administration approval. Although the combination has a manageable safety profile, many toxicities associated with the regimen may not be familiar to thoracic specialists or general oncologists. Extensive clinical experience with the combination in patients with metastatic melanoma has provided a wealth of strategies to identify and manage adverse events associated with dabrafenib plus trametinib. These can be used by medical oncologists to enhance early recognition of toxicities and facilitate effective management, thereby improving quality of treatment for patients.
AbstractCurrently, treatment of small bowel adenocarcinoma (SBA) mirrors that of colorectal cancer (CRC). Recent genomic data have demonstrated SBA to be a genetically unique entity, suggesting that therapies not traditionally utilized in CRC should be explored. In order to further characterize the activity of taxanes in this rare cancer, we completed a single‐center retrospective study. Twenty patients were found to have been treated with taxane‐based regimens (monotherapy in 3, combination therapy in 17). Median time to progression was 3.8 months (95% confidence interval [CI] 2.9–4.6), and median overall survival was 10.7 months (95% CI: 3.1–18.3). The results of this study demonstrate clinical activity from taxane‐based therapy in advanced SBA and support further clinical trial investigation.
Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):3-9
Conventional and advance technologies are available for laser hair removal. Complete and permanent hair reduction is not yet possible by treatment with lasers. Ideal patient for any conventional laser hair removal treatment is one who has thick, dark terminal hair, light skin and normal hormonal status. Factors that contribute to variable outcomes in laser hair removal can be broadly divided into patient related ones and the technology related ones. Skin type, hair color, thickness and density, degree of tan, hormonal dysfunction etc., constitute the patient related factors. The wavelength, fluence, spot size and pulse duration of the laser system are the technology related factors. There are some patients who respond variably, unpredictably or poorly to laser hair removal despite ensuring that indication for treatment is appropriate with adequate parameters of the laser system. This article reviews various patient related and technology related factors which lead to variable-to-poor outcomes in laser hair removal; and various challenges and limitations of laser hair removal technology in patients with dark skin types.
Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):10-17
The Q-switched Nd:YAG laser is an established modality of treatment for epidermal and dermal pigmented lesions. The dual wavelengths of 1064nm and 532nm are suited for the darker skin tones encountered in India. Though this laser has become the one of choice for conditions such as nevus of Ota, Hori's nevus and tattoos, its role in the management of melasma and other acquired dermal melanoses is not clear. Despite several studies having been done on the Q-switched Nd:YAG laser in melasma, there is no consensus on the protocol or number of sessions required. Acquired dermal melanoses are heterogenous entities with the common features of pigment incontinence and dermal melanophages resulting in greyish macular hyperpigmentation. This article reviews the current literature on laser toning in melasma and the role of the Q-switched Nd:YAG laser in stubborn pigmentary disorders such as lichen planus pigmentosus. As the pathology is primarily dermal or mixed epidermal-dermal in these conditions, the longer wavelength of 1064nm is preferred due to its deeper penetration. Generally multiple sessions are needed for successful outcomes. Low fluence Q-switched Nd:YAG laser at 1064nm utilizing the multi-pass technique with a large spot size has been suggested as a modality to treat melasma. Varying degrees of success have been reported but recurrences are common on discontinuing laser therapy. Adverse effects such as mottled hypopigmentation have been reported following laser toning; these can be minimized by using larger spot sizes of 8 to 10mm with longer intervals (2 weeks) between sessions.
Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):18-23
Several early reports suggested that performance of dermatosurgical procedures in patients on oral isotretinoin is associated with abnormal skin healing, keloid or hypertrophic scar formation. However, this association has been recently questioned in some studies. This review examines this issue, analyzes the studies published and concludes that the recommendation made earlier about the need to avoid dermatosurgical procedures in patients on isotretinoin is based on inadequate and insufficient evidence and hence needs revision. The review also suggests that recent studies on the subject establish that performing such procedures is safe.
Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):24-31
Lasers and light-based devices are indispensable to an aesthetic dermatology practice. The growing popularity of lasers has been matched by a sharp increase in the incidence of complications. The Indian skin with its high melanin content is more prone to injury and careful setting of laser parameters, early detection of complications and immediate therapy are vital to avoiding permanent sequelae. We review the various complications that occur during laser procedures and their management.
Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):32-38
Background: Accurate preparation of recipient area is a critical step in melanocyte-keratinocyte transplantation procedure for vitiligo. It is an important potential step for adaptation in the quest to achieve better results and ablative lasers potentially offer excellent precision over margin and depth control in achieving that. Objective: To compare between the two techniques used for recipient site preparation: Er:YAG laser ablation and mechanical dermabrasion for melanocyte-keratinocyte transplantation procedure in terms of re-pigmentation achieved and adverse effects seen. Methods: A randomized comparative trial was performed among 32 patients of stable vitiligo undergoing melanocyte-keratinocyte transplantation procedure. In Group A (n = 15), recipient site preparation was done with Er:YAG laser, and in Group B (n = 17), it was done with a motorized dermabrader. Patients of both groups were objectively assessed for re-pigmentation at 1, 3 and 6 months. Results: A total of 253.696 cm2 of depigmented surface was operated upon and re-pigmentation of 125.359 cm2 (49.4%) was achieved. On comparison between two groups, no statistical difference was found with respect to total re-pigmentation achieved (Group A: 54.67% vs Group B: 48.841%, P = 0.663) and grades of re-pigmentation achieved (P = 0.796). Occurrence of adverse events was also statistically similar in both the groups. Conclusion: This study did not reveal any statistically different outcome (in terms of re-pigmentation and adverse effects) between the two methods of recipient site preparation – motorized dermabrasion and Er:YAG ablation. Limitations: This study is small and larger studies are needed to ascertain the benefit of Er:YAG for recipient site preparation. Future studies may also ascertain variables such as time taken to prepare the recipient area, nature of bleeding, postoperative healing, difficulties in specific area, cost of the procedure, patient comfort and ease of the surgeon, rather than comparing the re-pigmentation alone.
Vinod K Khurana, Rachita R Misri, Swati Agarwal, Akhilesh V Thole, Sachin Kumar, Tanu Anand
Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):39-43
Background: Melasma poses a great challenge as its treatment modalities are unsatisfactory. Treatment using tranexamic acid is a novel concept. Aim: This study aimed to compare the therapeutic efficacy and safety of oral tranexamic acid and tranexamic acid microinjections in patients with melasma. Methods: This is a prospective, randomized, open-label study with a sample size of 64, 32 in each treatment arm. Thirty-two patients were administered localized microinjections (4 mg/ml) of tranexamic acid monthly in 1 arm, while in the other arm, 32 were given oral tranexamic acid 250 mg twice a day. Patients were followed up for 3 consecutive months. Clinical photographs were taken at each visit, and a modified melasma area and severity index scoring was performed at the beginning and end of treatment. Results: Improvement in melasma area and severity index score in the oral group was 57.5% as compared to 43.5% in the intralesional group. All 32 patients in the oral group (100%) showed >50% improvement, out of which 8 showed >75% improvement. In the intralesional group, 17 (53%) patients had >50% improvement, of which 3 had >75% improvement. The remaining 15 patients in this group had <50% improvement. Thus, the oral group showed a more significant response as compared to the intralesional group. No major adverse effects were observed in both the groups. At 6-month follow-up, two patients (6.2%) in the oral group had recurrence as compared to three patients (9.4%) in the intralesional group. Limitations: A small sample size was one of the limitations in this study. The dose of tranexamic acid in microinjections and the frequency of injections could have been increased. Conclusion: Tranexamic acid provides rapid and sustained improvement in the treatment of melasma. It is easily available and affordable. Oral route is undoubtedly efficacious, but the results of microinjections, while encouraging, can probably be enhanced by either increasing the frequency of injections or increasing the concentration of the preparation.
Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):44-50
Background: Available options for correction of facial volume loss, such as synthetic fillers, autologous fat and cultured fibroblasts, have limitations viz. temporary effect and high cost. Aim: To assess the use of a novel technique, autologous non-cultured dermal cell suspension transplantation, for correction of localized facial volume loss due to inflammatory pathologies. Methods: It was a pilot study conducted in the Dermatology Outpatient Department, All India Institute of Medical Sciences (AIIMS), New Delhi, India. Autologous non-cultured dermal cell suspension was transplanted in a total of 10 patients, out of which 5 had predominantly dermal loss and the rest had predominantly lipoatrophy. The donor tissue from the gluteal region was digested into a single cell suspension using collagenase-1 and injected into the recipient area. The outcome was assessed subjectively by patients and investigators and objectively using ultrasonography. Cell count, viability testing and measurement of mesenchymal stem cells were also done. Results: On assessment of patients, the median improvement in the predominantly dermal atrophy group at 3 and 6 months was 70% (range: 10–90%) and 80% (range: 0–90%), respectively, and in the predominantly lipoatrophy group, 0% (range: 0–40) and 0% (range: 0–50), respectively. Mean thickness of dermis + subcutis at the baseline was 1.835 mm (range: 0.89–6.04 mm), which increased to 2.912 mm (range: 0.88–7.07 mm, P = 0.03) at 6 months. Limitations: Our pilot study has some limitations such as small sample size and heterogeneity of the recruited patients. Conclusions: Autologous non-cultured dermal cell suspension transplantation appears to be safe and effective in localized facial dermal defects because of inflammatory pathologies, but not effective in deeper defects.
Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):129-129
Background and Aim: Treatment of palmoplantar warts is a challenge for dermatologists. We aimed to study the efficacy and safety of Falknor's needling method in palmoplantar warts. Methods: In an open, nonrandomized study, the index wart of eligible patients was punctured several times with a 26-gauge needle to produce a "beefy" red wound. Patients were followed up to 6 months. Results: Out of 82 patients, complete resolution occurred in 58 (70.7%) and partial response in 5 (6.1%) patients. Nine (10.9%) patients developed secondary infection. Limitations: Small sample size, No comparison group. Conclusion: Falknor's needling method provides a high rate of complete resolution after a single treatment session. It is easy to perform and is cost effective.
Mohamed El-Komy, Vanessa Hafez, Rania Abdel Hay, Dina Mehaney, Iman Hafez
Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):51-55
Background: Normal immune functioning requires sufficient levels of trace elements including zinc and selenium, while elements such as nickel can be immunotoxic. Aim: To assess long-term abnormalities in zinc, selenium and nickel levels in patients with chronic recurrent warts. Methods: Toenail samples were taken from 28 patients with chronic recurrent warts and 30 apparently healthy matching controls were analysed. Toenail concentrations of zinc, selenium and nickel were measured using inductively-coupled plasma-optical emission spectroscopy. Results: Selenium levels were significantly higher in patients than in controls (P = 0.03). Levels of trace elements did not correlate with the number or duration of warts. Toenail nickel levels in all subjects were higher than globally reported values. Limitations: A small sample size and the absence of regional reference ranges for concentrations of trace elements in toenails. Conclusion: Zinc does not seem to be involved in the chronicity of warts, and it is unclear if selenium has a protective role against warts. Our finding of high concentrations of nickel in both patients and controls raises concerns about environmental exposure.
Sonia Chavez-Alvarez, Alejandra Villarreal-Martinez, Ma Del Roble Velasco-Campos, Isabel Moreno-Vega, Laura Elia Martinez-de-Villarreal, Maira Herz-Ruelas, Jorge Ocampo-Candiani, Luis Daniel Campos-Acevedo
Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):130-130
Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):56-59
Advanced extramammary Paget's disease does not have a standardized treatment guideline as its incidence is low and has been rarely reported in literature. Here we describe a case of metastatic extramammary Paget's disease successfully treated with topical 5-fluorouracil (5-FU) and systemic pemetrexed. The therapy was safe without any appreciable adverse effects like diarrhea, rash, neutropenia or fatigue; maintaining remission for more than 6 months. Thus, we propose 5-FU and pemetrexed as the first-line therapy for advanced extramammary Paget's disease, especially for aged patients with unresectable skin lesions.
To describe a quality assurance issue, producing non-diagnostic high contrast radiographs, when imaging teeth restored with all zirconia crowns on bitewing radiographs.
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To analyze the immunohistochemical expression of fatty acid synthase (FASN) and cyclooxygenase-2 (COX‑2) in tooth germ (TG), ameloblastoma (AM), ameloblastic carcinoma (AC), ameloblastic fibroma (AF) and ameloblastic fibrosarcoma (AFS).
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Our previous study of patients with unilateral TMJ osteoarthritis (OA) showed that the affected joints had greater horizontal condylar angle (HCA) than contralateral unaffected joints. However, it was unclear whether the HCA changes preceded or were the result of OA changes. The aim of this study was to investigate the relationship between HCA and OA progression in a longitudinal study.
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This study analyzed and compared the immunoexpression of Regγ, Wnt-1 and β-catenin in ameloblastomas, adenomatoid odontogenic tumors (AOTs), and odontogenic keratocysts (OKCs).
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Epithelioid osteoblastoma is a clinically aggressive subtype of osteoblastoma that favors the mandible and maxilla. Its histological features lie on a spectrum between conventional osteoblastoma and low grade osteosarcoma, thus making it difficult at times to confirm the diagnosis. It is known to have a high risk of recurrence after surgical resection but it is a benign entity and lacks the propensity to metastasize. To our knowledge, there is no published literature on findings of epithelioid osteoblastoma on positron emission tomography/computed tomography (PET/CT).
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A 33-year-old Hispanic woman presented to the allergy and immunology clinic for recurrent angioedema. She was previously healthy until she began to experience intermittent, infrequent episodes of angioedema at age 25. Prior to evaluation, she had experienced seven episodes of angioedema affecting the extremities with no oropharyngeal or abdominal involvement. The angioedema was non-pruritic and was not associated with urticaria, trauma, foods, medication, infections, or menstruation. She did not take any medications, including angiotensin-converting enzyme inhibitors or hormonal therapies.
Increasing evidence suggests that aberrant expression of miR-495 is associated with the progression of various cancers. The aim of this study was to investigate the function and underlying mechanism of miR-495 in oral squamous cell carcinoma (OSCC).
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The orbito-zygomatic complex (OZC) includes several key structures, and its destruction leads to the impairment of functional activities such as nutrition, communication, nasal support, and vision. Management of benign tumors of the OZC is therefore a surgical challenge due to the necessity of reconstruction of these elements. Autogenous bone is considered to be the gold standard for reconstruction. Nevertheless, the difficulty is related to the complex anatomy and distorted skeletal anatomical landmarks, which require precise work in the case of bone grafts.
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Mandibular asymmetry due to Condylar Hyperactivity (CH) depicts a complex set of morphological features that pose challenges for its correction. Using state-of-the-art morphometric techniques, we provide a detailed and hierarchical description of the features present in CH-asymmetric mandibles, offering new knowledge for its surgical treatment.
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The extraction of third molars is the most common surgical procedure performed in the oral cavity. Coronectomy is a surgical protocol to reduce the risk of neurologic lesions to the inferior alveolar nerve (IAN). The authors look for early (up to 1 month) and late (from 2 to 60 months) postoperative complications.
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Dental rehabilitation in patients receiving free-flap reconstructive surgery to the mandible or maxilla is an important part of bringing patients back to normality both in a physical and a psychological way. It is therefore important to be able to do this in the fastest way possible.Virtual pre-planned reconstructions of jaws with implants placed simultaneously are a good way to expedite this process and has the advantage of allowing true backward planning to get the bone where it prosthetically needs to be.
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Reconstruction of mandibular substance loss by free flap is a widely used technique. This technique suffers from several disadvantages; these include the presence of a second intervention site and a significant frequency of complications. We have undertaken a custom-made three-dimensional reconstruction (using CAD/CAM) with prosthetic dental rehabilitation and esthetic improvement by lipomodelling of the face. A fifty-year-old woman presented with a massive recurrence of an ameloblastoma of the right hemimandible.
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Smartphone addiction has become a crucial social issue. Past studies have indicated that phone use such as talking or texting while walking constitutes a dual task that may cause pedestrians inattentional blin...
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While dehydroepiandrosterone (DHEA) may exert neuroprotective effects in the developing brain, prolonged or excessive elevations in cortisol may exert neurotoxic effects. The ratio between DHEA and cortisol (DC ratio) has been linked to internalizing and externalizing disorders as well as cognitive performance, supporting the clinical relevance of this hormonal ratio during development. However, the brain mechanisms through which these effects may be mediated have not been identified as of yet. Further, while there is evidence that the CNS effects of cortisol may be sexually dimorphic in humans, the opposite is true of DHEA, with human studies showing no sex‐specific associations in cortical thickness, cortico‐amygdalar or cortico‐hippocampal structural covariance. Therefore, it remains unclear whether sex moderates the developmental associations between DC ratio, brain structure, cognition and behavior. Here we examined associations between DC ratio, structural covariance of the hippocampus with whole‐brain cortical thickness, and measures of personality, behavior and cognition in a longitudinal sample of typically developing children, adolescents and young adults 6‐22 years (N=225 participants (F=128); 355 scans (F=208)), using mixed effects models that accounted for both within‐ and between‐subject variances. We found sex‐specific interactions between DC ratio and anterior cingulate cortex‐hippocampal structural covariance, with higher DC ratios associated with a more negative covariance between these structures in girls, and a more positive covariance in boys. Further, the negative prefrontal‐hippocampal structural covariance found in girls was associated with higher verbal memory and mathematical ability, while the positive covariance found in boys was associated with lower cooperativeness and reward dependence personality traits. These findings support the notion that the ratio between DHEA and cortisol levels may contribute, at least in part, to the development of sex differences in cognitive abilities as well as risk for internalizing/externalizing disorders, through an alteration in prefrontal‐hippocampal structure during the transition from childhood to adulthood.
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Existence and cause of thyroid stunning was controversially discussed for decades but the underlying mechanism remains unclear. Numerous studies describe thyroid stunning in radioiodine-131 therapy (RIT) of differentiated thyroid carcinoma. However, there are no studies evaluating thyroid stunning in benign thyroid diseases caused by the radioiodine uptake test (RIUT). Therefore, the influence of pre-therapeutic tracer radiation dose on therapeutic iodine-131 uptake was evaluated retrospectively.
Methods
A total of 914 RIT patients were included. Exclusion criteria were anti-thyroid drugs, pre- and/or intra-therapeutic effective half-lives (EHL) beyond 8.04 days and externally performed RIUT or 24 h RIUT. All patients received RIUT 1 week before RIT. Thyroid volume was estimated via ultrasound. Tracer radiation dose to the thyroid was calculated retrospectively. The dependence of changes in the pre-therapeutic to the therapeutic extrapolated-maximum-131I-uptake (EMU) from the dose in RIUT was evaluated statistically.
Results
EMU in RIUT ranged from 0.10 to 0.82 (median: 0.35) and EMU in RIT ranged from 0.10 to 0.74 (median: 0.33). Averaged over the whole cohort the therapeutic EMU decreased significantly (2.3% per Gray intra-thyroidal tracer radiation dose). A disease-specific evaluation showed dose-dependent thyroid stunning from 1.2% per Gray in solitary toxic nodules (n = 327) to 21% per Gray in goiters (n = 135) which was significant for the subgroups of disseminated autonomies (n = 114), multifocal autonomies (n = 178) and goiters (p < 0.05) but not for Graves' diseases (n = 160) and solitary toxic nodules (p > 0.05).
Conclusions
The presented data indicate for the first time a significant dependence of pre-therapeutic radiation dose on thyroid stunning in goiter and disseminated and multifocal autonomy. To achieve the desired intra-thyroidal radiation dose, RIT activity should be adapted depending on the dose in RIUT.
The minimal clinically important difference (MCID) of the 22‐item Sino‐Nasal Outcome Test (SNOT‐22) is specific but not sensitive for identifying patients experiencing noticeable improvement in symptoms of chronic rhinosinusitis (CRS). It is unclear why some patients with less than 1 MCID change in SNOT‐22 score nevertheless report noticeable improvement in their CRS symptoms.
Methods
This investigation was a retrospective study of 247 CRS patients undergoing medical management who completed SNOT‐22 surveys in 2 consecutive visits 2‐12 months apart. The validated nasal, sleep, ear/facial discomfort, and emotional SNOT‐22 subdomain scores were calculated. At the second visit, patients reported their global change in CRS symptoms on a 5‐item transition rating scale as: "Much worse"; "A little worse"; "About the same"; "A little better"; or "Much better." Patient‐reported improvement in symptoms (at least "A little better") was tested for association with changes in SNOT‐22 subdomain scores.
Results
In the entire cohort, patient‐reported improvement in CRS symptoms was associated with improvement in all SNOT‐22 subdomain scores (p < 0.001). In patients with less than 1 MCID (12 points) of change in the SNOT‐22, only the nasal subdomain (adjusted odds ratio, 0.89; 95% confidence interval [CI], 0.79‐0.99; p = 0.042) was associated with patient‐reported improvement in CRS symptoms. Changes in none of the other SNOT‐22 subdomain scores were associated with patient‐reported improvement in CRS symptoms.
Conclusions
Among patients with less than 1 MCID change in the SNOT‐22, improvement in only nasal symptoms—but not extranasal symptoms—of CRS is associated with those who nevertheless report improvement of their CRS symptoms.
Objective: In this study, we have described the technique to overcome difficulty faced during trans-foraminal endoscopic discectomy for the treatment of lumbar radiculopathy in patients who have herniated discs at the upper lumbar level & thoracolumbar junction. Method: After institutional review board approval, A retrospective analysis of 27 patients operated between March 2013- September 2017, by a single specialist for disc herniation at upper lumbar levels D12-L1, L1-2, L2-3 with or without high canal compromise by outside in technique (using rigid endoscope, sequential reamers) along with detailed description of our technique is the focus of this study. Results: Out of 27 patients there were 11 cases for L1-2 & 16 cases of L2-3 disc herniation respectively. There were 21 cases of broad-based, high canal compromised disc herniation with significant neurological deficit & only 6 cases were of focal herniation type. The average preoperative VAS score of 8.5 (range 6-10) reduced to 4 (range 2-7) immediate postoperatively & it further reduced to 2 (range 0-4) at one month follow up. The average preoperative ODI score of 65 (range 28- 88) reduced to 27 (range 12-40) immediate postoperatively & it further reduced to 10 (range 3- 18) at one month follow up. Post-operative MRI showed that the ruptured disc had been successfully removed. Conclusion: An anatomically modified surgical technique promote a more successful outcome after percutaneous endoscopic discectomy for upper lumbar disc herniation. Foraminotomy is recommended for all intra-canalicular herniation. Transforaminal endoscopic discectomy and foraminotomy can be used as a safe yet minimally invasive technique for the treatment of lumbar radiculopathy in the setting of an upper lumbar disc herniation.
Neuropathic pain (NeP) constitutes a major pain-related disorder, which is often underdiagnosed and undertreated. Adverse physical, psychological, and economic consequences associated with NeP lead to poor quality of life. Burden of NeP in developing countries like India is colossal. Various international guidelines provide effective approaches to diagnose and manage NeP. However, differences in the genetic makeup of Indian population can result in subtle differences in clinical response, considering their low body weight, drug metabolism ability, and pain perception. Similarly, treatment-related adverse effects may also vary. Practice of Indian physicians may also differ for choice of drugs based on their availability and affordability. In the absence of country-specific guidelines, this document could serve as a guiding tool for health-care providers, ensuring uniformity in the treatment of NeP. Thus, applicability of all recommendations from any of these guidelines in Indian setting demands careful evaluation. Clinical experience of Indian physicians suggests that there are lot many challenges (e.g., busy outpatient departments, nonavailability of screening questionnaires in regional languages, and availability and affordability of medications) faced by them when managing NeP. In addition, in India, there are no country-specific guidelines that would help them to address these challenges. The objective for this consensus was to develop an expert opinion guideline to harmonize the management of NeP in India. The expert panel consisted of experts from various specialties such as pain medicine, anesthesiology, diabetology, neurology, and orthopedics. The panel critically reviewed the existing literature evidence and guideline recommendations to provide India-specific consensus on the management of NeP. The final consensus document was reviewed and approved by all the experts. This expert opinion consensus will help health-care professionals as a guiding tool for effective management of NeP in India. Use of Douleur Neuropathique 4 (DN4) questionnaire for NeP screening should be routine in day-to-day clinical practice. For effective utilization of DN4 questionnaire, it should be converted to regional language. If DN4 questionnaire screening fails to identify NeP, it should not be disregarded and should not replace the sound clinical judgment from the treating physician. Diagnostic tests may be considered as a supplement to clinical judgment. Cost-effective treatment should be the initial choice. Dosing should be individualized based on efficacy and tolerability. Tricyclic antidepressants (TCAs), gabapentinoids, and serotonin-norepinephrine reuptake inhibitors (SNRIs) can be considered among initial choices. Tramadol can be considered as a second-line add-on treatment for NeP if there is partial response to the first-line agent either alone or in combination. Fixed-dose combination (FDC) of gabapentinoids such as pregabalin (75 mg) with TCA such as nortriptyline (10 mg) is synergistic and improves treatment adherence. Among other treatments, Vitamin B12 (methylcobalamin) can be used either alone or in combination for the management of NeP. Use of Vitamin D and steroids should be limited to specific NeP in individual cases. Referral to pain specialists can be considered if two drugs fail to provide relief in NeP.
Is tactile acuity altered in individuals with acute mechanical neck pain?
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Shobhalakshmi S Holla, Turiya Vats, Pratima Nagpal DOI:10.4103/ijpn.ijpn_20_18
Background: Tactile acuity measured by point discrimination (TPD) refers to the precision by which we can sense touch.An increase in TPD threshold (loss of tactile acuity) is considered suggestive of disruptions to S1 cortical maps of that specific body part. In some chronically painful conditions, reduced tactile acuity is a manifestation of Central sensitization (CS).The other symptoms include hyperalgesia and allodynia due to repeated activation of spinal nociceptors. A recent study has shown that tactile acuity is affected in individuals with chronic neck pain. While there seems to be adequate evidence stating that tactile acuity is reduced in individuals with chronic pain, CS may not be limited to chronic pain states. There is a paucity of literature with respect to the tactile acuity of a person with acute neck pain. A measurement of tactile acuity of the affected body area in acute pain, may suggest the extent of the altered threshold of sensory discriminative aspect of pain experience. Objectives: To compare the two-point discrimination over C7 spinous process between the symptomatic individuals with mechanical neck pain and age matched healthy controls. Methods: 30 individuals with mechanical neck pain & 30 age matched normals were assessed for two point discrimination using mechanical calipers, The two sharp points of the caliper were vertically placed against the skin surface over C7 spinous process, commencing with 5mm, which was stretched out till the subject appreciated the two points. Values were noted down in millimeters. Results: An independent t – test showed a significant difference in the two point discrimination between the 2 groups (P < 0.000). Conclusion: It can be concluded that individuals with acute mechanical neck pain demonstrated a change in tactile acuity.
A comparative study of ultrasound-guided femoral nerve block versus fascia iliaca compartment block in patients with fracture femur for reducing pain associated with positioning for subarachnoid block
Context: Lower extremity peripheral nerve blocks are increasingly being recommended for pain control in patients with fracture femur as it reduces pain and shortens the duration of hospital stay. Aims: To compare analgesic efficacy of ultrasound guided femoral nerve block (FNB) and fascia iliaca compartment block (FICB) in patients with fracture femur for reducing pain associated with positioning for subarachnoid block. Settings and Design: It was a prospective, randomized, double blind study. Methods and Material: Group A (n = 25) received ultrasound guided FNB and Group B (n = 25) received ultrasound guided FICB using 0.5% ropivacaine. Primary objective was to observe reduction in pain associated with positioning (sitting) for subarachnoid block. Statistical Analysis used: For data analysis t test, Mann Whitney test and Chi-square test were applied. Results: Visual analog scale (VAS) score for pain before giving peripheral nerve block between Group A (7.60 ± 0.57) and Group B (7.44 ± 0.50) was comparable (P = 0.302). VAS score for pain in sitting position before giving subarachnoid block was lesser in Group A (1.88 ± 0.83) than in Group B (2.40 ± 0.57) (P = 0.013). Mean reduction in VAS score for pain was more in Group A (5.72 ± 0.73) compared to Group B (5.04 ± 0.73) (P = 0.002). Conclusion: Ultrasound guided FNB is more efficacious in reducing pain associated with positioning (sitting) for subarachnoid block in patients undergoing surgery for fracture femur compared to ultrasound guided FICB.
Aims: 1. Study the change in pain and function in patient with lumbosacral disc disease on MRI using visual analogue scale (VAS) and the revised Oswestry disability index (ODI) for back pain after administration of fluoroscopically guided transforaminal epidural injection. 2. Correlate the response of the patient with the spread of contrast in epidural space. Method: 100 patients with history of low back ache and imaging findings of disc herniation were enrolled based on inclusion criteria. Patients scored their pain on the VAS and functional disability on revised ODI. The patient was evaluated for distribution of pain and was administered a combination of anaesthetic and steroid after confirming the position of the tip of needle using iodinated contrast. Follow up for response to pain and improvement in disability in immediate post procedure done at 3 and 6 months. Result: 102 injections were administered for 100 patients which comprised of n=69 {67.6%} male and 33{32.4%} female and age distribution was 21-79 years. The distribution of indication was disc bulge n=29 (28.4%), extrusion n=12 (11.8%), post operative n=19 (18.6%), protrusion n=42 (41.2%). No significant difference between the VAS scores (p=0.20) of the individual indication pre procedure. After 3 & 6 months there was statistically significant difference between the mean rank value of population indicating maximum benefit for disc bulge population and least for post operative population at three months follow up. Conclusion: There is statistically proven good results in all cases for 6 months, after which repeat injections may be tried.
Perception, knowledge, and attitudes of first-year postgraduates toward postoperative pain management: A questionnaire-based study
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Pritam B Adsule, Pradnya M Bhalerao, Prakash R Dhumal DOI:10.4103/ijpn.ijpn_31_18
Context: Inadequately controlled postoperative pain has undesirable physiological and psychological consequences. It increases postoperative morbidity, delays recovery, and hence causes a delayed return to normal daily living. Furthermore, the lack of adequate postoperative pain treatment may lead to persistent pain after surgery, which is often overlooked. Overall, inadequate pain management increases the use of health care resources and health care costs. Aim: To evaluate the knowledge and attitudes of first-year postgraduate students toward postoperative pain. Study Design: This questionnaire-based cross-sectional study was conducted on 42 first-year postgraduate students. Materials and Methods: A 20-point questionnaire was prepared based on the various aspects of postoperative pain services. The students were asked to provide their answers on a five-point Likert scale ranging from "strongly disagree" to "strongly agree." The responses were kept anonymous, and the results were expressed in terms of percentage. Results:Almost 70% of students had a good knowledge of opioids, 52% strongly felt the need for a structured pain curriculum, 76% were well aware of nonpharmacological methods of pain relief, 48% agreed on the need for a pain physician, and 52% were aware of the advantage of postoperative analgesia. Conclusion: This pilot study helped us to evaluate the current understanding of our first-year postgraduate students and further created awareness on the importance of pain relief postoperatively.
Executive function and its clinical correlates among migraineurs
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Ashitha Sreedhar, Suresh M Kumar, Anjali N Shobha DOI:10.4103/ijpn.ijpn_38_18
Background: The studies conducted in the field of migraine and its effect on various cognitive functions revealed contradicting results mainly due to the incorporation of patients from varied socioeconomic status, clinical conditions, and the methodology adopted to the study. Methods: The participants of the study consist of 130 migraineurs, selected from the outpatient department of neurology from reputed tertiary centers at Chennai, South India, and controls were picked up from the community. Patients were selected on the basis of clinical examination and screening. The instruments used are Migraine Severity Scale, Headache impact test, hospital anxiety and depression scale (HADS), Wisconsin Card Sorting Test, Trail Making Test, and Controlled Oral word Association Test. Results: The study found that migraine group to have deficits in some aspects of problem-solving and concept formation competencies in comparison with healthy individuals and also found strong and weak correlation with various clinical variables such as its severity, duration, and headache impact indicating the role of migraine on cognitive functioning. Conclusion: The condition of migraine does lead to mild-to-moderate levels of impairment in various frontal lobe-involved cognitive functions such as attention, planning, and problem-solving even in a high-profile samples having higher levels of education and occupation. The relation between the migraine and impairment in cognitive functions are further cemented by the strong correlation found between various clinical factors such as its severity, duration, and its impact. Findings from such a study will also pave new ways and means to incorporate the implementation of a holistic approach in the treatment and management of migraine, and thereby to enhance the quality of life of these patients.
Translation and validation of Marathi version of Fear-Avoidance and Belief Questionnaire in patients with chronic low back pain
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Vrushali P Panhale, Reshma S Gurav, Kartiki Suradkar DOI:10.4103/ijpn.ijpn_41_18
Background: Fear-Avoidance Beliefs Questionnaire (FABQ) is widely used to assess the fear-avoidance beliefs in patients with low back pain (LBP). However, English serves as a barrier to the population of the state where Marathi is the prime language. Hence, the FABQ needs to be translated into Marathi for the ease of its use. Materials and Methods: FABQ was successfully translated in Marathi using forward-backward translation using recommended guidelines. The final version of FABQ-Marathi version (FABQ-M) was used on 100 patients with chronic nonspecific LBP to assess its reliability and validity. Reliability was assessed by measuring the internal consistency of FABQ-M and its subscales and by checking the test-retest reliability on day 1 and day 2. For the determination of construct validity, convergent and divergent validity was assessed. The floor and ceiling effects were studied. Results: Reliability-internal consistency-Cronbach's alpha for FABQ-M was 0.860 and test–retest: correlation between FABQ-M on day 1 and day 2 were highly significant. The intraclass coefficient was 0.976. There was a high internal consistency between the FABQ-M and its subscales. On assessing convergent validity, there was moderate correlation found between FABQ-M and TSK (r = 0.52, P = 0.00). Divergent validity showed moderate correlation between FABQ-M and NRS (r = 0.48, P = 0.00) and between FABQ-M and RMDQ (r = 0.59, P = 0.00). Conclusion: The translated FABQ-M proved to be acceptable. The results suggest it is a validated, an easy to comprehend, reliable, and valid instrument for the measurement of the fear and avoidance beliefs caused by back disorders in the Marathi-speaking population.
Cancer is a life changing diagnosis and chronic pain in these terminally ill patients is extremely debilitating. In the present case series, the feasibility of continuous infusion of low dose local anaesthetics and opioids through the intrathecal route has been discussed pertaining to patient selection, technique, drugs used and trouble shooting. The intrathecal catheters were connected through a subcutaneous port to an external ambulatory infusion device (CADD pump) and used on a home care basis.
Quadratus lumborum is one of the common sources of pain and that can be missed or ignored easily. Quadratus lumborum pain syndrome is a myofascial pain syndrome. The pain is due to spasm and stiffness of the muscle. Many a times, weak back muscles are compensated by quadratus lumborum leading to painful spasm. It is diffi cult to differentiate between quadratus lumborum and iliopsoas pain syndrome. Diagnostic quadratus lumborum injection helps differentiate between these two. In this report, we reported a case of quadratus lumborum pain syndrome as a primary diagnosis and iliopsoas pain syndrome as a secondary diagnosis. The diagnosis was confi rmed by fl uoroscopically guided quadratus lumborum injection.
A 50-year-old female presented with severe pain at the cholecystectomy scar site of 4 months' duration. She had an open cholecystectomy done followed by continuous pain from the time of discharge. She was diagnosed as a case of chronic postsurgical pain (CPSP) syndrome. We administered right-sided erector spinae (ES) block by ultrasound guidance depositing 15 ml of 0.25% bupivacaine and 40 mg of methylprednisolone at site of incision. The visual analog score showed significant improvement from 7/10 to 2/10 for the next 2 months of follow-up. We conclude that ultrasonography-guided ES block combined with intralesional steroid is a viable treatment option in cases of CPSP. This is possibly the first case report of postcholecystectomy chronic pain managed with ES block.
Cervical epidural steroid injection is an intervention done for cervical prolapsed intervertebral disc. Cervical epidural steroid injection is done if a patient has not responded to medications and physical therapy. We discuss a case report of the occurrence of Horner's syndrome in the patient with cervical radiculopathy undergoing cervical interlaminar epidural steroid injection which resolved spontaneously without residual side effects.
BACKGROUND Recent investigations noted noninferiority in short-course antimicrobial treatments following source control in abdominal infections. We set out to investigate noninferiority of a short and fixed (24 hours) antibiotic administration compared to extended treatment after source control in complicated appendicitis in a prospective single-center open-label randomized controlled trial. METHODS After Institutional Review Board (IRB) approval, all consecutive adult patients (age, ≥ 18 years) with complicated appendicitis including gangrenous appendicitis, perforated appendicitis, and appendicitis with periappendicular abscess between May 2016 and February 2018 were randomly allocated to antibacterial therapy limited to 24 hours (short) vs. >24 hours (extended) administration after appendectomy. Primary outcomes included composite postoperative complications and Comprehensive Complication Index (CCI). Secondary outcome was hospital length of stay (HLOS). Follow-up analysis at 1 month was conducted per intention and per protocol. RESULTS A total of 80 patients were enrolled with 39 and 41 cases allocated to the short and the extended therapy group, respectively. Demographic profile and disease severity was similar between the study groups. Overall rate of complications was 17.9% and 29.3% in the short and extended group, respectively (p = 0.23). Mean CCI did not differ between the study groups (p = 0.29). Hospital length of stay was significantly reduced in the short therapy group (61 ± 34 hours vs. 81 ± 40 hours, p = 0.005). CONCLUSION In the current prospective randomized investigation, the short (24 hours) antibiotic administration following appendectomy did not result in a worse primary outcome in complicated appendicitis. The short interval administration resulted in a significant reduction in HLOS with a major cost-saving and antibacterial stewardship perspective. LEVEL OF EVIDENCE Therapeutic Level IV.
