Outcome of Judet's quadricepsplasty for knee contractures and the effect of local infiltration of epinephrine on reducing blood loss

Objective: To evaluate the effectiveness of Judet''s quadricepsplasty for treatment of knee contractures and to identify the effect of local infiltration of epinephrine on blood loss associated with this procedure. Methods: A retrospective cohort study was conducted in which all cases of knee contractures managed with Judet''s quadricepsplasty from 1st January 2009 to 31st December 2013 were included and were divided into two groups. The epinephrine group included patients who were infiltrated with diluted epinephrine (1:400,000) along with xylocaine, around the operative field 15 min prior to the incision time, while the control group did not receive any infiltration. Judet''s outcome, blood loss, drop in hemoglobin and required blood transfusion were noted for all patients and compared between both groups. Results: Most common preceding pathology identified for the development of knee contractures was periarticular fracture while ilizarov application was the most common etiology. Both groups were found similar in all preoperative characteristics except preoperative flexion contracture (p=0.02). All functional outcome measures including Judet''s outcome were similar in both groups. In contrast, duration of surgery (p=0.01), blood loss (p=0.02), drop in hemoglobin (p=0.01) and number of transfusions (p=0.03) were significantly reduced in epinephrine group. Conclusion: Judet''s quadricepsplasty is a useful procedure to increase the range of motion of rigid knees and local infiltration of epinephrine is effective in decreasing the amount of subsequent blood loss and transfusion requirements.     

Gastrointestinal perforation in children due to blunt abdominal trauma in Hazara,Northern Pakistan

A retrospective study of 25 children with gastrointestinal perforation due to blunt abdominal trauma in a single region of Pakistan is presented. The age, sex, aetiology, site of perforation, abdominal and X-ray findings, associated injuries, surgical procedures and outcome were analysed. There were 20 boys and 5 girls: mean age was 10 years. The injuries were the result of road traffic accidents 12 (48%), falls 11 (44%) and 'struck by animals' two (8%). Associated injuries occurred in 19 (76%). On admission 20 (80%) patients had peritonitis while 18 (72%) had pneumoperitoneum. Mean time from trauma to admission was 10 hours and admission to operation was 5 hours. Ileum was the most common site of perforation. Simple closure was the most common surgical procedure. Complications occurred in nine (36%) patients--six (24%) died. Delay in presentation and operation was associated with increased morbidity and mortality. Frequent evaluation of the child and abdominal X-rays are still the important tools for early diagnosis of gastrointestinal perforation following blunt abdominal trauma.     

Effectiveness and safety profiling of zolpidem and acupressure in CKD associated pruritus: An interventional study

Background:Chronic kidney disease (CKD)-associated pruritus (CKD-aP) contributes to poor quality of life, including reduced sleep quality and poor sleep quality is a source of patient stress and is linked to lower health-related quality of life. This study aimed to investigate the effectiveness of zolpidem 10 mg and acupressure therapy on foot acupoints to improve the sleep quality and overall quality of life among hemodialysis patients suffering from CKD-aP.Method:A multicenter, prospective, randomized, parallel-design, open label interventional study to estimate the effectiveness of zolpidem (10 mg) oral tablets versus acupressure on sleep quality and quality of life in patients with CKD-aP on hemodialysis. A total of 58 hemodialysis patients having sleep disturbance due to CKD-aP completed the entire 8-week follow-up. The patients were divided into a control (acupressure) group of 28 patients and an intervention (zolpidem) group of 30 patients.Results:A total of 58 patients having CKD-aP and sleep disturbance were recruited. In the control group there was a reduction in the PSQI score with a mean ± SD from 12.28 ± 3.59 to 9.25 ± 3.99, while in the intervention group the reduction in PSQI score with a mean ± SD was from 14.73 ± 4.14 to 10.03 ± 4.04 from baseline to endpoint. However, the EQ5D index score and EQ-visual analogue scale (VAS) at baseline for the control group with a mean ± SD was 0.49 ± 0.30 and 50.17 ± 8.65, respectively, while for the intervention group the values were 0.62 ± 0.26 and 47.17 ± 5.82, respectively. The mean EQ5D index score in the control group improved from 0.49 ± 0.30 to 0.53 ± 0.30, but in the intervention group there was no statistical improvement in mean EQ5D index score from 0.62 ± 0.26 to 0.62 ± 0.27 from baseline to week 8. The EQ 5D improved in both groups and the EQ-VAS score was 2.67 points higher at week 8 as compared to baseline in the control group, while in the intervention group the score was 3.33 points higher at week 8 as compared to baseline. Comparing with baseline, the PSQI scores were significantly reduced after week 4 and week 8 (P =  < .001). Furthermore, at the end of the study, the PSQI scores were significantly higher in the control as compared to the intervention group (P = .012).Conclusion:An improvement in sleep quality and quality of life among CKD-aP patients on hemodialysis has been observed in both the control and intervention groups. Zolpidem and acupressure safety profiling showed no severe adverse effect other that drowsiness, nausea and daytime sleeping already reported in literature of zolpidem.     

Impact of COVID-19 Pandemic on Training: Global Perceptions of Gastroenterology and Hepatology Fellows in the USA

Background

The COVID-19 pandemic has impacted numerous facets of healthcare workers’ lives. There have also been significant changes in Gastroenterology (GI) fellowship training as a result of the challenges presented by the pandemic.

Aims

We conducted a national survey of Gastroenterology fellows to evaluate fellows’ perceptions, changes in clinical duties, and education during the pandemic.

Methods

A survey was sent to Gastroenterology (GI) fellows in the USA. Information regarding redeployment, fellow restriction in endoscopy, outpatient clinics and inpatient consults, impact on educational activities, and available wellness resources was obtained. Fellows’ level of agreement with adjustments to clinical duties was also assessed.

Results

One hundred and seventy-seven Gastroenterology fellows responded, and 29.4% were redeployed to non-GI services during the pandemic. COVID-19 impacted all aspects of GI fellowship training in the USA (endoscopy, outpatient clinics, inpatient consults, educational activities). Fellows’ level of agreement in changes to various aspects of fellowship varied. 72.5% of respondents reported that their programs provided them with increased wellness resources to cope with the additional stress during the pandemic. For respondents with children, 17.6% reported no support with childcare.

Conclusions

Our results show that the COVID-19 pandemic has impacted GI fellowship training in the USA in multiple domains, including gastrointestinal endoscopy, inpatient consults, outpatient clinics, and educational conferences. Our study highlights the importance of considering and incorporating fellows’ viewpoints, as changes are made in response to the ongoing pandemic.

     

The yield of stool testing in hospital-onset diarrhea: Has evidence changed practice?

Introduction: Aside from examination for Clostridium difficile, the yield of stool testing in hospital-onset diarrhea is poor. Clinical practice guidelines discourage overzealous stool testing in patients with diarrhea that develops after the third hospital day. However, the adoption of this recommendation into clinical practice is limited. Furthermore, the effect of microbiology laboratory improvements on hospital-onset diarrhea testing is largely unknown. Methods: A retrospective cohort study was conducted in a university-affiliated community-hospital and included all adult inpatients who developed diarrhea after hospitalization. Results: 132 adult patients (53% female) developed diarrhea after hospitalization in 2013. The cohort’s mean age was 55.6 years. 46.2% of patients developed diarrhea in the first 3 days of hospitalization. Testing for parasites was negative in all examined 67 samples. Testing for C. difficile was positive in 13 cases (10.8%) out of 120 tested samples. Testing for other pathogens was positive in 1 sample (Campylobacter) out of 129 samples. Stool samples tested in the first 3 days of hospitalization were more likely to be positive (64.3 vs 35.7%, p = 0.1). Change in management was reported in 9 out of 14 patients (64.3%) with positive stool testing compared with 31 out of 118 patients (26.3%) with negative stool testing, p = 0.01. Conclusion: Despite improvements in stool samples’ testing, the yield continues to be low, especially in hospital-onset diarrhea past the third hospital day. Physicians’ embracement of the ‘3-day rule’ continues to be poor.     

Advances in neuroimaging for HIV-1 associated neurological dysfunction: clues to the diagnosis, pathogenesis and therapeutic monitoring

Persons with advanced human immunodeficiency virus type one (HIV-1) infection seek medical advice for a wide range of neurological disorders including, but not limited to, peripheral neuropathy, toxoplasmosis, cryptococcal meningitis, cytomegalovirus retinitis progressive multifocal leukoencephalopathy, lymphoma and dementia. The diagnosis of HIV-1-associated dementia (HAD) induced as a direct consequence of HIV infection of the brain comes commonly by exclusion. Diagnostic decisions can often be clouded by concomitant depression, motor impairments, and lethargy that follow debilitating immune suppression and weight loss. Indeed, cognitive, motor and behavior abnormalities underlie a variety of neurological dysfunctions associated with advanced HIV-1 infection. Thus, even combinations of clinical, laboratory and neuroimaging tests [for example, magnetic resonance imaging (MRI), computed tomography (CT), single photon emission computed tomography (SPECT) and positron emission tomography (PET)] often fail to provide conclusive diagnostic information. Nonetheless, the recent development of quantitative MR spectroscopic imaging has improved diagnostic possibilities for HAD. We are pleased to discuss these developments as well as taking a forward look into what will soon be made available to improve neuroimaging diagnostic precision. New MR and SPECT testing are being developed in our laboratories and elsewhere both for animal model systems and in humans with HIV-1 disease. Such tests can facilitate dynamic measures of HIV-1 neuropathogenesis providing information for disease events that even 2 years ago were unattainable.     

Association of FcγRIIa Polymorphism with Clinical Outcome of Dengue Infection: First Insight from Pakistan

Dengue illness has been a major health concern in Pakistan during the last decade. Dengue infection can result in a spectrum of clinically distinct outcomes, ranging from asymptomatic infection to potentially life-threatening forms of dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). A single-nucleotide polymorphism in FcγRIIa (rs1801274) results in altered affinity of the receptor for different subclasses of immunoglobulin G, and is a key player in determining the susceptibility to or protection from severe clinical infection of dengue. In this study, we analyzed the allelic and genotypic distribution of rs1801274 in subjects of Pakistani origin with subclinical dengue infection (n = 40), dengue fever (DF) (n = 40), and DHF/DSS (n = 30). We found that HH homozygotes and heterozygotes were significantly more likely to develop clinical dengue (odds ratio [OR] = 3.21, 95% confidence interval [CI] = 1.29–7.97, P = 0.009), either DF (OR = 2.82, 95% CI = 1.00–7.97, P = 0.045) or DHF/DSS (OR = 3.90, 95% CI = 1.13–13.07, P = 0.024) than the asymptomatic dengue infection. Results of allelic distribution comparisons and logistic regression analysis also supported the same relationship. The results suggest complex nature of interacting factors in determining the course for severe dengue illness.