Minimum 10-year follow-up outcomes of arthroscopic Bankart’s repair with metallic anchors:Reliable results with low redislocation rates

BACKGROUND With stiff competition from alternative albeit more expensive counterparts,it has become important to establish the applicability of metallic anchors for shoulder instability in the modern era.This can be accomplished,in part,by analysing long-term outcomes.AIM To analyse minimum 10-year outcomes from 30 patients following arthroscopic anterior stabilisation using metallic anchors.METHODS Prospectively collected data from arthroscopic Bankart repairs performed using metal anchors during 2007P-2010 were retrospectively analysed in this singlesurgeon study.Comprehensive data collection included historical and clinical findings,dislocation details,operative specifics,and follow-up radiological and clinical findings including shoulder scores.The primary outcomes were patientreported scores(Constant,American Shoulder and Elbow Surgeons[ASES],and Rowe scores)and pain and instability on a visual analogue scale(VAS).RESULTS A 3% recurrence rate of dislocation was noted at the final follow-up.Total constant scores at 10 years postoperatively measured between 76 and 100(mean 89)were significantly better than preoperative scores(mean 62.7).Congruous improvements were also noted in the Rowe and ASES scores and VAS at the 10-year review.CONCLUSION Reliable long-term outcomes with metallic anchors in surgery for shoulder instability can be expected.Our results provide additional evidence of their continued,cost-effective presence in the modern scenario.

Cryptococcosis in kidney transplant recipients:Current understanding and practices

Cryptococcosis is the third most commonly occurring invasive fungal disease in solid organ transplant recipients(SOT).It is caused by encapsulated yeast,Cryptococcus species,predominantly Cryptococcus neoformans and Cryptococcus gattii.Though kidney transplant recipients are at the lowest risk of cryptococcosis when compared to other solid organ transplant recipients such as lung,liver or heart,still this opportunistic infection causes significant morbidity and mortality in this subset of patients.Mortality rates with cryptococcosis range from 10%-25%,while it can be as high as 50%in SOT recipients with central nervous system involvement.The main aim of diagnosis is to find out if there is any involvement of the central nervous system in disseminated disease or whether there is only localized pulmonary involvement as it has implications for both prognostication and treatment.Detection of cryptococcal antigen(CrAg)in cerebrospinal fluid or plasma is a highly recommended test as it is more sensitive and specific than India ink and fungal cultures.The CrAg lateral flow assay is the single point of care test that can rapidly detect cryptococcal polysaccharide capsule.Treatment of cryptococcosis is challenging in kidney transplant recipients.Apart from the reduction or optimization of immunosuppression,lipid formulations of amphotericin B are preferred as induction antifungal agents.Consolidation and maintenance are done with fluconazole;carefully monitoring its interactions with calcineurin inhibitors.This review further discusses in depth the evolving developments in the epidemiology,pathogenesis,diagnostic assays,and management approach of cryptococcosis in kidney transplant recipients.

Portal biliopathy

Biliary ductal changes are a common radiological finding in patients with portal hypertension, however only a small percentage of patients (5%-30%) develop symptomatic bile duct obstruction. The exact pathogenesis is not clear, but an involvement of factors such as bile duct compression by venous collaterals, ischemia, and infection is accepted by most authors. Although endoscopic retrograde cholangiopancrea- tography was used to define and diagnose this condition, magnetic resonance cholangiopancreatography is currently the investigation of choice for diagnosing this condition. Treatment is indicated only for symptomatic cases. Portosystemic shunts are the treatment of choice for symptomatic portal biliopathy. In the majority of patients, the changes caused by biliopathy resolve after shunt surgery, however, 15%-20% patients require a subsequent bilio-enteric bypass or endoscopic management for persistent biliopathy. There is a role for endoscopic therapy in patients with bile duct stones, cholangitis or when portosystemic shunt surgery is not feasible.

Correlation of transient elastography with hepatic venous pressure gradient in patients with cirrhotic portal hypertension: A study of 326 patients from India

AIM To study the diagnostic accuracy of transient elastography(TE) for detecting clinically significant portal hypertension(CSPH) in Indian patients with cirrhotic portal hypertension.METHODS This retrospective study was conducted at the Institute of Liver, Gastroenterology, and Panceatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, on consecutive patients with cirrhosis greater than 15 years of age who underwent hepatic venous pressure gradient(HVPG) and TE from July 2011 to May 2016. Correlation between HVPG and TE was analyzed using the Spearman's correlation test. Receiver operating characteristic ( ROC) curves were prepared for determining the utility of TE in predicting various stages of portal hypertension. The best cut-off value of TE forthe diagnosis of CSPH was obtained using the Youden index.RESULTS The study included 326 patients [median age 52(range 16-90) years; 81% males]. The most common etiology of cirrhosis was cryptogenic(45%) followed by alcohol(34%). The median HVPG was 16.0(range 1.5 to 30.5) mm Hg. Eighty-five percent of patients had CSPH. A significant positive correlation was noted between TE and HVPG(rho 0.361, P < 0.001). The area under ROC curve for TE in predicting CSPH was 0.740(95%CI: 0.662-0.818)(P < 0.01). A cut-off value of TE of 21.6 k Pa best predicted CSPH with a positive predictive value(PPV) of 93%.CONCLUSION TE has a fair positive correlation with HVPG; thus, TE can be used as a non-invasive modality to assess the degree of portal hypertension. A cut-off TE value of 21.6 k Pa identifies CSPH with a PPV of 93%.

Advancing frontiers in anaesthesiology with laparoscopy

The introduction of laparoscopy in the surgeon's armamentarium was in fact a "revolution in the history of surgery". Since this technique involves insufflation of carbon dioxide it produces several pathophysiological changes which have to be understood by the anaesthesiologist who can modify the anaesthesia technique accordingly. Advantages of laparoscopy include reduced pain, small scars and early return to work. Certain complications specific to laparoscopic surgery are due to carboperitoneum and increased intra-abdominal pressure. Venous air embolism, although very rare, can be lethal if not managed promptly. Other complications include subcutaneous emphysema, haemodynamic compromise and arrhythmias. Although associated with minimal postoperative morbidity, postoperative pain, nausea and vomiting can be quite problematic. The limitations of laparoscopy have been overcome by the introduction of robotic surgery. There are important implications for the anaesthesiologist during robotic surgeries which have to be practiced accordingly. Robotic surgery has a learning curve for both the surgeon and the anaesthesiologist. The robot is bulky, and cannot be disengaged after docking. Therefore it is important that the anaesthetized patient remains immobile throughout surgery and anaesthesia is reversed only after the robot has been disengaged at the end of surgery. Advances in laparoscopy and robotic surgery have modified anaesthetic techniques too.

Management of gastric variceal bleeding:Role of endoscopy and endoscopic ultrasound

Gastric varices(GVs)are notorious to bleed massively and often difficult to manage with conventional techniques.This mini-review addresses endoscopic management principles for gastric variceal bleeding,including limitations of ligation and sclerotherapy and merits of endoscopic variceal obliteration.The article also discusses how emerging use of endoscopic ultrasound provides optimism of better diagnosis,improved classification,innovative management strategies and confirmatory tool for eradication of GVs.

Comparative analysis of APACHE-Ⅱ and P-POSSUM scoring systems in predicting postoperative mortality in patients undergoing emergency laparotomy

BACKGROUND Laparotomy remains one of the commonest emergency surgical procedures.Early prognostic evaluation would aid in selecting the high-risk patients for an aggressive treatment.Awareness about risks could potentially contribute to the quality of perioperative care and optimum utilization of resources.Portsmouth modification of Physiological and operative severity for the enumeration of mortality and morbidity (P-POSSUM) and the acute physiology and chronic health evaluation Ⅱ(APACHE-Ⅱ) have been the most widely used scoring systems for emergency laparotomies.It is always better to have a single scoring system to predict outcomes and audit healthcare organizations.AIM To compare the ability of APACHE-II and P-POSSUM to predict postoperative morbidity and mortality in patients undergoing emergency laparotomy.METHODS All patients undergoing emergency laparotomy at the Tata Main Hospital,Jamshedpur between December 2013 and November 2014 were included in the study.In this observational study,P-POSSUM and APACHE-Ⅱ scoring were done,and the outcome analysis evaluated with mortality being the primary outcome.RESULTS For P-POSSUM,at a cut off value of 63 to predict mortality using receiver operating characteristics curve analysis,the area under the curve was 0.989;and for APACHE-Ⅱ,at the cut off value of 24,the area under the curve was 0.965.CONCLUSION Because the ability of APACHE-Ⅱ to predict mortality was similar to P-POSSUM and APACHE-Ⅱ does not need scoring for intra-operative findings and histopathology reports,APACHE-Ⅱ can be used pre-operatively to assess the risk in patients undergoing emergency laparotomy.However,for audit purposes,either of the two scoring systems can be used.

Delayed Mesh Infection: A Rare Complication of Laparoscopic Inguinal Hernia Repair (TEP—Totally Extra-Peritoneal Repair)

Hernias are amongst the oldest afflictions of mankind. The tension-free mesh repairs revolutionized and radically changed the whole concept of anatomical tissue repairs. The introduction of mesh, though beneficial, posed a new set of postoperative problems with the mesh infection being the most morbid one. Laparoscopic surgery has been able to reduce the incidence of mesh infection as opposed to the open hernia repairs. The infection occurs mostly early but rarely does it present several years after the surgery. Herein we report our case of delayed mesh infection developing 6 years postoperatively. This is our first such case in a series of more than 1000 laparoscopic hernia repairs over a period of 6 years (2010-2016). The patient needed an open exploration which revealed a large preperitoneal cavity containing 770 ml of pus with a mesh floating in it. The mesh was removed and the thorough toileting of the wound was done.

IGF2 ApaI A/G Polymorphism Evaluated in ESRD Individuals as a Biomarker to Identify Patients with New Onset Diabetes Mellitus after Renal Transplant in Asian Indians

Insulin like growth factors2 (IGF2) regulates pancreatic β-cell renewal and apoptosis, which in turn plays a role in altering insulin activity and glucose homeostasis. Polymorphisms in IGF2 gene have been associated with altered levels of IGF2. Hence, ApaI polymorphism in exon 9 of IGF2 (rs#680) gene was assessed in patients with end stage renal disease (ESRD) to identify individuals at risk of developing new onset diabetes mellitus (NODM) in Asian Indians. Isolated DNA was used for PCR&RFLP based genotyping of IGF2 ApaI polymorphism which was carried out in 364 individuals these included 140 patients who had undergone renal transplant, 42 of which developed new onset diabetes mellitus after renal transplant and 224 healthy control volunteers. In the present study NODM or post transplant diabetes mellitus (PTDM) showed a significant association with G allele and AG genotype when compared with the Non-NODM ESRD patients after transplant (OR 2.081, 95% CI = 1.191 - 3.634, p = 0.01 and OR 3.188, 95% CI = 1.498 - 6.785, p = 0.002) ESRD patients with healthy controls also showed an association with G allele and AG genotype (OR 1.512, 95% CI = 1.060 - 2.155, p = 0.02 and OR 2.235, 95% CI = 1.453 - 3.438, p = 0.0002). IGF2 could be used as a biomarker to identify individuals at high risk of developing NODM, it would be a valuable asset in selecting appropriate immunosuppressive regimens for individuals undergoing transplant. Present study shows the importance of IGF2 ApaI polymorphism in assessing the risk of NODM in ESRD individuals in Asian Indians with ESRD.

Nephrogenic systemic fibrosis:A frivolous entity

Gadolinium-based contrast agents(GBCAs)used in magnetic resonance imaging are vital in providing enhanced quality images,essential for diagnosis and treatment.Nephrogenic systemic fibrosis(NSF)with GBCAs has been a deterrent for the physician and has led to avoidance of these agents in patients with impaired kidney function.NSF is a progressive debilitating multisystem condition described classically in patients with renal insufficiency exposed to gadolinium contrast media.It is characterized by an induration and hardening of the skin.NSF is described to first involve the extremities and can imperceptibly involve internal organs.Lack of therapeutic interventions to treat NSF makes it more challenging and warrants deep insight into the pathogenesis,risk factors and treatment strategies.

Beneficial effect of refined red palm oil on lipid peroxidation and monocyte tissue factor in HCV-related liver disease： a randomized controlled study

BACKGROUND： A large amount of endotoxin can be detected in the peripheral venous blood of patients with liver cirrhosis, contributing to the pathogenesis of hepatotoxicity because of its role in oxidative stress. The present study aimed to test the effect of the supplementation with red palm oil（RPO）, which is a natural oil obtained from oil palm fruit（Elaeis guineensis） rich in natural fat-soluble tocopherols, tocotrienols and carotenoids, on lipid peroxidation and endotoxemia with plasma endotoxin-inactivating capacity, proinflammatory cytokines profile, and monocyte tissue factor in patients with chronic liver disease. METHODS： The study group consisted of sixty patients（34 males and 26 females; mean age 62 years, range 54-75） with Child A/B, genotype 1 HCV-related cirrhosis without a history of ethanol consumption, randomly enrolled into an 8-week oral daily treatment with either vitamin E or RPO. All patients had undergone an upper gastrointestinal endoscopy 8 months before, and 13 out of them showed esophageal varices.RESULTS： Both treatments significantly decreased erythrocyte malondialdehyde and urinary isoprostane output, only RPO significantly affected macrophage-colony stimulating factor and monocyte tissue factor. Liver ultrasound imaging did not show any change. CONCLUSIONS： RPO beneficially modulates oxidative stress and, not least, downregulates macrophage/monocyte inflammatory parameters. RPO can be safely advised as a valuable nutritional implementation tool in the management of chronic liver diseases.

Pigmented Villonodular Tenosynovitis of the Temporomandibular Joint—A Case Report

Background: Pigmented villonodular synovitis is a rare condition typically affecting the major joints and the involvement of the temporomandibular joint is rare. Although, it is histologically benign, it can be locally aggressive, capable of extensive bone destruction. The disease has aggressive behavior and a high incidence of recurrence (40% - 60%). Case report: A 35 years old male presented with history of unilateral hearing loss and otalgia of six month duration. On examination, there was a soft bulge in the superior wall of external auditory canal. Contrast enhanced CT scan showed soft tissue density occupying the right external auditory canal and bulging into the middle ear cavity, displacing the intact ossicular chain medially with evidence of destruction of the posterior wall of the external auditory canal, glenoid fossa, mastoid bone and the scutum. The squamous part of the right temporal bone showed evidence of lateral bowing with discontinuity. Surgical resection was done through post aural approach. Histopathological examination revealed pigmented villonodular tenosynovitis which stained positive for CD 68. Post operatively patient was evaluated clinically and with radiological modalities which showed healthy mastoid cavity and no increase in post operative granulations on magnetic resonance imaging. Conclusion: Pigmented villonodular tenosynovitis of temporomandibular joint is a rare entity. Due to the aggressive behavior of the lesion, radical or aggressive surgical resection should be done. Long term follow up with radiological modality should be done due to the high recurrence rate.

Hypergammaglobulinemic purpura of waldenstorm associated with sjogren’s syndrome in a young female responding to rituximab treatment

Hypergammaglobulinemic Purpura of Waldenstorm is one of the uncommon conditions with purpura and is often associated with collagen vascular disease. It is difficult to treat and sometimes needs anti CD 20 molecules for resistant cases.

Cardiopulmonary Bypass for Tracheal Resection and Repair—A Safe Alternative

Airway management during tracheal surgery is always challenging for the anaesthesia team. Cardiopulmonary bypass (CPB) is generally not required during tracheal surgery on the cervical trachea. However, for tracheal surgeries CPB may be advantageous and give the surgeon more freedom to work. We report three cases of post-intubation tracheal stenosis successfully managed with tracheal resection and reconstruction performed under cardiopulmonary bypass.

Immunogenicity, Safety and Efficacy Comparison of Wockhardt’s Biosimilar Insulin Glargine—Glaritus®with Reference Product— Lantus®: Study Protocol &Early Data Trends

Objective: Present Phase IV Trial is aimed at evaluating the immunogenicity, safety, and efficacy of Wockhardt’s insulin glargine, Glaritus&reg;in comparison with reference insulin glargine, Lantus&reg;in subjects with type 2 diabetes mellitus (T2DM), inadequately controlled on oral hypoglycaemics. Setting: A head-to-head, prospective, open-label, parallel group, randomized, Phase IV, non-inferiority study over 6 months treatment conducted in 10 centres in India. Participants: Considering 20% drop-out rate, 180 subjects of either sex, age 18 - 55 years, diagnosed with T2DM with body mass index (BMI) 18 - 38 kg/m2 and HbA1c levels 8.0% - 10.0% inadequately controlled by 1 or more oral hypoglycaemics and according to investigator needed glargine treatment were enrolled in the study. Interventions: Subjects self-administered insulin glargine (Glaritus&reg;or Lantus&reg;) subcutaneously once daily for 6 months. Treatment in Glaritus&reg;arm was continued till 12 months. Percentage change in anti-insulin antibody (AIA) titre and HbA1C was ascertained at every 3 months interval. The tests were performed at accredited central laboratory. Treat-to-target dose titration: Starting doses of Glaritus&reg;and Lantus&reg;was 10 units (or 0.2 units/kg) once daily. The target fasting blood glucose was 70 to 130 mg/dL. Daily glargine dose was titrated by ±10% based on average of last 3 FBG values being out of target range and presence of nocturnal hypoglycemia. Early data trends: First interim analysis was planned once 100 subjects complete visit 8 (6 months treatment). By then, 119 subjects (78 males and 41 females) with mean age 46.3 years were enrolled, of which 90 (75.6%) subjects had evaluable data. The results of analysis indicated trend of comparability between Glaritus&reg;and Lantus&reg;at the end of 6 months in terms of immunogenicity (% change in AIA titre from baseline, &minus;10.52 ± 23.06 vs. 0.48 ± 63.95), glycemic control (change in HbA1c from baseline, &minus;1.09% ± 1.29% vs. 0.63% ± 1.19%) and hypoglycemic events (reported by 1 vs. 2 patients), respectively. Conclusion: The present study represents a robust design in line with international guidelines on biosimilar insulin development and the early data trends presents expected similarity of Glaritus&reg;in immunogenicity, efficacy and safety to that of Lantus&reg;in treatment of T2DM.

Carcinosarcoma of the Hypopharynx—A Rare Entity with Unique Surgical Procedure

Background: Carcinosarcoma of hypopharynx is a rare neoplasm with both malignant epithelial and mesenchymal components. They are highly aggressive in nature with controversial histogenesis. To our knowledge, there is no case reported of carcinosarcoma of hypopharynx managed with wide LASER excision and modified radical neck dissection followed by chemoradiation. Method and Result: 42-year-old male presented complaints of foreign body sensation in throat, and difficulty in swallowing and hoarseness for 4 months. On examination, a large smooth globular mass filling the supraglottis obscuring the view of endolarynx was noted and right side level-II cervical lymphadenopathy was found. CECT neck revealed a large hypopharyngeal mass abutting the supraglottis. Microlaryngoscopic biopsy was reported as high grade carcinosarcoma and PET scan was done after 1 week which revealed no any distant metastasis. The patient was taken for transoral pulsed carbon dioxide LASER excision with modified radical neck dissection, and postoperative chemoradiation was done and after two years of closed follow-up MRI was done which revealed no disease and the patient is absolutely free of disease till now. Conclusion: It was a rare case which was managed with complete LASER excision with neck dissection and postoperative chemoradiation and the patient is absolutely free of disease till now after 2 years of follow-up.

Neurofibroma of the Pinna

Neurofibromas are relatively common lesions of the nervous system, but only a few cases involving the pinna have been reported. Isolated neurofibroma of pinna without neurofibromatosis has not been reported in the literature so far. Neurofibromas may develop anywhere in the body, including cranial and peripheral nerves. The type of impairment associated with neurofibromas depends largely on the site of the lesion. Cutaneous lesions, especially in the head and neck, generally cause deformity, whereas lesions that affect deeper systems (e.g., the auditory and ocular systems) are more likely to cause functional impairment. Usually found in individuals with neurofibromatosis, we report a case of neurofibroma of pinna in a patient without

Vaccines and Antibodies for Therapeutic Use in Cancers

This review describes briefly the beneficial use of two vaccines developed by us for treatment of cancers. The vaccine against Luteinizing Hormone Releasing Hormone (LHRH) is effective in carcinoma of prostate as well as in breast cancers dependent on androgens and estrogens respectively. LHRH being identical in both males and females, the same vaccine is usable in both Prostate and Breast steroid hormones-dependent-cancers. Monoclonal antibodies are finding therapeutic utility in several cancers, and many have received Drugs Regulatory approval. The monoclonals developed by us against hCG and against epitopes present on androgen-independent castration resistant prostate cancers are briefly recapitulated. Anti-hCG antibodies kill several cancers expressing hCG. An example is given of A549 lung carcinoma. MoAb730 and MoAb7B2G10 kill DU-145 and PC-3 androgen-independent castration resistant prostate cancer cells. Some cancers such as MOLT-4, a T-lymphoblastic leukemia, though expressing hCG are not killed by PiPP, the high affinity anti-hCG antibody. Linking the antibody to curcumin however works like a “Magic Bullet”. All MOLT-4 cells are killed by this conjugate, the antibody homes selectively to cancer cells expressing hCG to deliver curcumin which exercises the killing effect. A recombinant vaccine, hCGβ-LTB (human chorionic gonadotropin subunit β linked to B subunit of heat-labile enterotoxin of E. coli) has been made, which induces high titre bioeffective antibodies not only in BalbC, but also in other genetic strains of mice. The vaccine employs autoclaved Mycobacterium indicus pranii (MiP) as adjuvant. MiP invigorates both humoral and cell mediated immune responses against Human chorionic gonadotropin (hCG). Besides being a potent adjuvant, MiP used alone heals anogenital warts in humans and has the property of preventing and curing SP2/O Myelomas in mice.

High Resolution Computed Tomography Features of Third Wave of COVID-19 Pneumonia in Confirmed Cases

COVID-19 which is caused by its new type called SARS-CoV-2 is a viral disease predominantly involving the lungs. Objective: To investigate HRCT features of pulmonary disease in COVID-19 in Lahore, Pakistan. Methods: This is a prospective study that involved 127 COVID-19 positive patients (age 18 - 80 years, both genders) through non-probability sampling was conducted at the Radiology Department, Sir Ganga Ram Hospital, Lahore, in 2021. All patients with RT-PCR positive underwent HRCT chest. All findings in HRCT chest were assessed. Confirmed patients had positive HRCT. Excluded situations are low quality of images irrespective of its reason, HRCT indications other than COVID-19 pneumonia, and patients who do not want to participate in the study Results: Considering the exclusion and inclusion criteria, totally 127 COVID-19 confirmed patients ranging age from 18 to 80 years with a mean age of 52 ± 18 years, took part in this study. The most important and common HRCT finding was the multilobar ground-glass pattern which was present in 95% of patients. Other findings including, crazy paving pattern, consolidation, air bronchogram, and bronchiectasis were present in 8.7%, 82%, 63%, and 37% of patients respectively. Pleural effusion seen in 21% patients. 16% of patients had mediastinal lymphadenopathy. Conclusion: In our study, the ground-glass pattern was found to be the most common and important HRCT finding in patients confirmed with COVID-19 pneumonia. This important HRCT pattern is mostly found to be in posterobasal and peripheral subpleural locations. Other than ground-glass pattern, bronchiectasis, and consolidation having the air bronchogram were also reported commonly.

Robotic-assisted esophagectomy: A literature review and our experience at a tertiary care centre

Esophageal cancer is a common cancer with a high case-related mortality worldwide,and radical resection offers the best survival.Initial reports have suggested that esophagus is an ideal organ which could benefit with robotic assistance.However,it remains to be seen whether robotic technology translates into better surgical outcomes and survival for the patients with esophageal cancer.We searched PubMed,Scopus and Google Scholar for English language articles.The search terms included minimally invasive esophagectomy or MIE,robotic-assisted esophagectomy,hybrid esophagectomy,robot-assisted minimal invasive esophagectomy or RAMIE,esophageal cancer,esophageal carcinoma.We review the development of robotic-assisted esophagectomy to focus on the surgical techniques and oncological clearance,and present a brief summary of our experience in this approach.Controlled trials will be required to establish the benefit of robotic-assisted esophagectomy,however the current literature points towards the safety and feasibility of this approach.