Thigh Pain and Peri-Implant Fractures with the Use of Short Cephalo-medullary Nails: A Retrospective Study of 122 Patients

@#Introduction: To assess the incidence and causes of persistent thigh pain and peri-implant fractures after union in patients of intertrochanteric fractures treated with short cephalo-medullary nails. Materials and methods: A retrospective observational study conducted at a Level 1 Trauma centre. A total of 122 patients of intertrochanteric fractures who were operated using short cephalo-medullary nails (170mm and 200mm lengths) between January 2018 to June 2019 were included in the study. Main outcomes measured were the incidence of thigh pain and peri-implant fractures. Results: Out of the 122 patients with a mean follow-up of 14.1 month, 12 patients had persistent thigh pain. Six patients had the helical blade protruding from the lateral cortex, two of them had distal tip of nail abutting on the anterior cortex and four cases had prominent proximal segment of nail which may explain the cause of their pain. Five of these patients had a combination of these findings. Two patients had pain for which no other obvious cause was found. There were no cases of peri-implant fractures in our study. Conclusion: Thigh pain associated with the use of short cephalon-medullary nails is often unrelated to nail length and can be prevented by using proper surgical technique. There seems to be no association between the use of short nails and peri-implant fractures.

Do technological advances in linear accelerators improve dosimetric outcomes in stereotaxy? A head‑on comparison of seven linear accelerators using volumetric modulated arc therapy‑based stereotactic planning.

INTRODUCTION: Linear accelerator (Linac) based stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) using volumetric modulated arc therapy (VMAT) has been used for treating small intracranial lesions. Recent development in the Linacs such as inbuilt micro multileaf collimator (MLC) and flattening filter free (FFF) beam are intended to provide a better dose conformity and faster delivery when using VMAT technique. This study was aimed to compare the dosimetric outcomes and monitor units (MUs) of the stereotactic treatment plans for different commercially available MLC models and beam profiles. MATERIALS AND METHODS: Ten patients having 12 planning target volume (PTV)/gross target volume’s (GTVs) who received the SRS/SRT treatment in our clinic using Axesse Linac (considered reference arm gold standard) were considered for this study. The test arms comprised of plans using Elekta Agility with FFF, Elekta Agility with the plane beam, Elekta APEX, Varian Millennium 120, Varian Millennium 120HD, and Elekta Synergy in Monaco treatment planning system. Planning constraints and calculation grid spacing were not altered in the test plans. To objectively evaluate the efficacy of MLC‑beam model, the resultant dosimetric outcomes were subtracted from the reference arm parameters. RESULTS: V95%, V100%, V105%, D1%, maximum dose, and mean dose of PTV/GTV showed a maximum inter MLC ‑ beam model variation of 1.5% and 2% for PTV and GTV, respectively. Average PTV conformity index and heterogeneity index shows a variation in the range 0.56–0.63 and 1.08–1.11, respectively. Mean dose difference (excluding Axesse) for all organs varied between 1.1 cGy and 74.8 cGy (mean dose = 6.1 cGy standard deviation [SD] = 26.9 cGy) and 1.7 cGy–194.5 cGy (mean dose 16.1 cGy SD = 57.2 cGy) for single and multiple fraction, respectively. CONCLUSION: The dosimetry of VMAT‑based SRS/SRT treatment plan had minimal dependence on MLC and beam model variations. All tested MLC and beam model could fulfil the desired PTV coverage and organs at risk dose constraints. The only notable difference was the halving of the MU for FFF beam as compared to the plane beam. This has the potential to reduce the total patient on couch time by 15% (approximately 2 min).

Influence of monte carlo variance with fluence smoothing in VMAT treatment planning with Monaco TPS.

INTRODUCTION: The study aimed to investigate the interplay between Monte Carlo Variance (MCV) and fluence smoothing factor (FSF) in volumetric modulated arc therapy treatment planning by using a sample set of complex treatment planning cases and a X‑ray Voxel Monte Carlo–based treatment planning system equipped with tools to tune fluence smoothness as well as MCV. MATERIALS AND METHODS: The dosimetric (dose to tumor volume, and organ at risk) and physical characteristic (treatment time, number of segments, and so on) of a set 45 treatment plans for all combinations of 1%, 3%, 5% MCV and 1, 3, 5 FSF were evaluated for five carcinoma esophagus cases under the study. RESULT: Increase in FSF reduce the treatment time. Variation of MCV and FSF gives a highest planning target volume (PTV), heart and lung dose variation of 3.6%, 12.8% and 4.3%, respectively. The heart dose variation was highest among all organs at risk. Highest variation of spinal cord dose was 0.6 Gy. CONCLUSION: Variation of MCV and FSF influences the organ at risk (OAR) doses significantly but not PTV coverage and dose homogeneity. Variation in FSF causes difference in dosimetric and physical parameters for the treatment plans but variation of MCV does not. MCV 3% or less do not improve the plan quality significantly (physical and clinical) compared with MCV greater than 3%. The use of MCV between 3% and 5% gives similar results as 1% with lesser calculation time. Minimally detected differences in plan quality suggest that the optimum FSF can be set between 3 and 5.

DNA pattern recognition using canonical correlation algorithm.

We performed canonical correlation analysis as an unsupervised statistical tool to describe related views of the same semantic object for identifying patterns. A pattern recognition technique based on canonical correlation analysis (CCA) was proposed for finding required genetic code in the DNA sequence. Two related but different objects were considered: one was a particular pattern, and other was test DNA sequence. CCA found correlations between two observations of the same semantic pattern and test sequence. It is concluded that the relationship possesses maximum value in the position where the pattern exists. As a case study, the potential of CCA was demonstrated on the sequence found from HIV-1 preferred integration sites. The subsequences on the left and right flanking from the integration site were considered as the two views, and statistically significant relationships were established between these two views to elucidate the viral preference as an important factor for the correlation.

A Bacteriological Study of Vibrio cholerae Isolated from Rural Tertiary Care Hospital of Loni, Western Maharashtra.

Aim: Cholera is endemic in many parts of India and a major public health problem. The present study was carried out with the aims to understand biotype, serotype, phage type and drug resistance of Vibrio cholerae isolates obtained at a rural tertiary care hospital in Loni. Study Design: Descriptive retrospective study was carried out to study V. cholerae isolates from 544 faecal specimens of patients with acute gastroenteritis. Place and Duration of Study: The study was conducted during 2009-2012 at Rural Medical College of Pravara Institute of Medical Sciences, Loni, District Ahmednagar, Maharashtra, India. Methods: A total of 28 isolates of V. cholerae were included in the study. V. cholerae was identified by standard microbiological procedures. Biotyping, serotyping and phage typing was done. Antibiotic sensitivity testing was performed by Kirby- Bauer disc diffusion method. Results: V. cholerae strains were isolated from 28 faecal specimens. All the isolates were identified as V. cholerae O1 biotype El Tor serotype Ogawa and phage 27 was the predominant type. Male: Female ratio was 1:1.5 and high incidence was seen in 0-10 age group (35.71%). Maximal occurrence in monsoon season was recorded. All the isolates were resistant to co-trimoxazole, nalidixic acid and ampicillin. However maximum sensitivity was observed to norfloxacin (71.42%) followed by gentamycin (67.85%) and chloramphenicol (28.57%). Conclusion: A continuous surveillance for V. cholerae is required with respect to changing epidemiology and emergence of antibiotic resistance strains. The source and spread of infection should be investigated to decide the proper management strategies. Additionally, quality of water and status of sanitation should be monitored.

Serum Lipid Profile status of Type 2 Diabetic Patients in the cross section population in Dhaka City of Bangladesh.

Objectives: Serum lipid profile viz the level of total cholesterol (TC), Triglyceride (TG), HDL-cholesterol and LDL-cholesterol of type2 diabetic patients have been studied and compares them with levels of control subjects. Results: The mean value of the TG level for male diabetics was higher than that for the female diabetics and the mean values of TC, HDL-C and LDL-C were not found significantly different between male and female diabetics. Hyperlipidemia has a documented causative relation with CAD, but the major risk associated with diabetes may be due to the associated hyperlipidemia. The study revealed that dyslipidemia is very common in type2 diabetics and the most common abnormality observed was increased serum triglyceride levels (58%). The next common abnormality was decreased serum high-density lipoprotein cholesterol (HDL-C) levels and increased serum low-density lipoprotein cholesterol (LDL-C) levels. A high total serum cholesterol levels was found in 41% patients. 39% of the patients examined were overweight, and 7% were overtly obese. Conclusion: Thus, the study clearly shows the relationship between type2 diabetes and hyperlipidemia, which may influence the mechanism by which type2 diabetes is associated with increased CAD risk.

Epidemiology & antibiograms of Vibrio cholerae isolates from a tertiary care hospital in Chandigarh, north India.

Background & objectives: Cholera is endemic in Chandigarh and its surrounding areas. This retrospective study was undertaken over a period of nine years (January 1999-December 2007) from a tertiary care hospital in north India to understand the changing epidemiology aspects and antibiotic resistance patterns in Vibrio cholerae isolates. Methods: A total of 277 isolates of V. cholerae were included in the study. V. cholerae was identifi ed by standard microbiological procedures. Antibiotic sensitivity testing was performed by disc diffusion method and isolates phage typed. Results: All the isolates were identifi ed as V. cholerae O1 biotype El Tor serotype Ogawa; phage 27 was the predominant type. Men were more commonly affected with maximum number in the age group 0-5 yr. Majority of the isolates were resistant to furazolidone but sensitive to gentamicin and cefotaxime. Resistance pattern to amoxycillin was variable. Three isolates were found to be resistant to ciprofl oxacin. All the patients presented during June-October coinciding with the monsoon season and a majority were from suburbs. Interpretation & conclusions: The emergence of resistance amongst V. cholerae especially towards ciprofl oxacin may signifi cantly infl uence the control strategies in future outbreaks. Phage 27 remained the predominant type in all the years. Continuous surveillance with regard to drug resistance, early detection and a strong regional commitment may help contain the disease.

Occurrence, significance & molecular epidemiology of cholera outbreaks in West Bengal.

BACKGROUND & OBJECTIVE: Diarrhoeal disease outbreaks are causes of major public health emergencies in India. We carried out investigation of two cholera outbreaks, for identification, antimicrobial susceptibility testing, phage typing and molecular characterization of isolated Vibrio cholerae O1, and to suggest prevention and control measures. METHODS: A total of 22 rectal swabs and 20 stool samples were collected from the two outbreak sites. The V. cholerae isolates were serotyped and antimicrobial susceptibility determined. Pulsed- field gel electrophoresis (PFGE) was performed to identify the clonality of the V. cholerae strains which elucidated better understanding of the epidemiology of the cholera outbreaks. RESULTS: Both the outbreaks were caused by V. cholerae O1 (one was caused by serotype Ogawa and the other by serotype Inaba). Clinically the cases presented with profuse watery diarrhoea and dehydration. All the tested V. cholerae isolates were sensitive to tetracycline, gentamycin and azithromycin but resistance for ampicillin, co-trimoxazole, nalidixic acid, and furazolidone. PFGE pattern of the isolates from the two outbreaks revealed that they were clonal in origin. Stoppage of the source of water contamination and chlorination of drinking water resulted in terminating the two outbreaks. INTERPRETATION & CONCLUSION: The two diarrhoeal outbreaks were caused by V. cholerae O1 (Inaba/Ogawa). Such outbreaks are frequently seen in cholera endemic areas in many parts of the world. Vaccination is an attractive disease (cholera) prevention strategy although long-term measures like improvement of sanitation and personal hygiene, and provision of safe water supply are important, but require time and are expensive.

Epidemiological, microbiological & electron microscopic study of a cholera outbreak in a Kolkata slum community.

BACKGROUND & OBJECTIVE: Epidemics of cholera caused by Vibrio cholerae O1 or O139 have been reported from different parts of India. Factors such as unsafe water supply, poor environmental sanitation, indiscriminate defaecation and lack of personal hygiene are mainly responsible for continued transmission of this disease. We report here epidemiological and microbiological findings of a localized outbreak of cholera, which occurred during March and April 2004 in the eastern part of Kolkata city. METHODS: The affected slum area has a population of 4409, predominantly muslims. Patients suffering from acute watery diarrhoea attended the health outposts organized by National Institute of Cholera and Enteric Diseases, Kolkata and International Vaccine Institute, South Korea as part of a routine surveillance programme at the locality as well as the emergency medical camp organized by the Kolkata Municipal Corporation. Stool and water samples were collected and tested for diarrhoeagenic pathogens in the laboratory. Bacteriophages specific for V. cholerae were isolates and studied electron microscopically for morphology. RESULTS: A total of 89 diarrhoea cases were reported giving an attack rate of 2 per cent. V. cholerae O1 biotype ElTor, serotype Ogawa was isolated as a sole pathogen from 15 (15.8%) of 89 stool samples screened. Water samples (2 from tube wells, 3 from municipal taps and 1 from well) showed presence of coliform bacilli with high MPN (Most Probable Number) count. Bacteriophages specific to V. cholerae were isolated from 2 of 6 water samples examined. A leakage was detected in the main pipeline supplying drinking water to that area. INTERPRETATION & CONCLUSION: The outbreak was caused by V. cholerae O1 (Ogawa) biotype ElTor. The presence of phages in the water samples was an additional indicator for V. cholerae contamination in this community. Occurrences of such outbreaks support vaccination against cholera as an alternative strategy.

An el tor cholera outbreak amongst tribal population in Tripura.

An outbreak of acute diarrhoeal disease occurred in Dhalai and North Tripura district, Tripura during month of May 2004. An investigation was done to identify causative agent with anti microbial susceptibility pattern and to know the epidemiological feature. Overall attack rate and Case Fatality Rate (CFR) was 18.8%. and 6.9/1000 respectively. Vibrio cholerae O1 biotype El Tor, Ogawa was isolated as sole pathogen in 40% of hospitalized acute diarrhoea patient and from a water samples examined. The strains were sensitive to Tetracycline, Doxycycline, Norfloxacin, Ciprofloxacin, Chloramphenicol, and Azithromycin. Bad peridomestic sanitation, use of contaminated surface water along with low literacy, lack of personal hygiene, frequent movement might be the factor associated with persistence and spread of pathogen amongst tribal groups leading to outbreak of cholera.

Deciphering diversity in populations of various linguistic and ethnic affiliations of different geographical regions of India: analysis based on 15 microsatellite markers.

The extent of genetic polymorphism at fifteen autosomal microsatellite markers in 54 ethnically, linguistically and geographically diverse human populations of India was studied to decipher intrapopulation diversity. The parameters used to quantify intrapopulation diversity were average allele diversity, average heterozygosity, allele range (base pairs), and number of alleles. Multilocus genotype frequencies calculated for selected populations were utilized for testing conformity with the assumption of Hardy-Weinberg equilibrium. The exact test values, after Bonferroni correction, showed significant deviation amongst Gowda (vWA, Penta E); Dhangar, Satnami and Gounder (D8S1179); Hmar (FGA); Kuki and Balti (vWA) groups. Relatively low number of alleles and allelic diversity (base-pairs size) had been observed in populations of central India as compared with southern and northern regions of the country. The communities of Indo-Caucasoid ethnic origin and Indo-European linguistic family (Kshatriya of Uttar Pradesh) showed highest allelic diversity, as well as rare alleles, not reported in any other Indian populations. Analysis based on average heterozygosity was also found to be lowest among the populations of central India (0.729) and highest among the populations from north (0.777) and west (0.784) regions of the country, having Indo-Caucasoid ethnic origin and Austro-Asiatic linguistic affiliation. The maximum power of discrimination (85%-89%) had been observed at loci FGA, Penta E, D18S51 and D21S11, suggested high intrapopulation diversity in India. Genetic diversity revealed by STR markers was consistent with the known demographic histories of populations. Thus, the present study clearly demonstrated that the intrapopulation diversity is not only present at the national level, but also within smaller geographical regions of the country. This is the first attempt to understand the extent of diversity within populations of India at such a large scale at genomic level.

Bacteriological profile of cholera in Tamil Nadu (1980-2001).

BACKGROUND & OBJECTIVE: In addition to Vibrio cholerae O1, a recently emerged non-O1 serotype, V. cholerae O139 has also been found to be responsible for epidemics of cholera. In the context of the changing etiology of cholera, the occurrence of different serotypes, biotypes and phage types of V. cholerae in Tamil Nadu is presented. METHODS: Between 1980 and 2001, 26,502 stool/rectal swabs from patients suspected to have cholera were processed for the presence of V. cholerae at the King Institute of Preventive Medicine, Chennai (Madras), Tamil Nadu. Serotypes, biotypes and phage types (Basu & Mukerjee and new phage typing method) of the isolates were determined. Antimicrobial susceptibility determination was included from 1997 onwards. RESULTS: Of the 26,502 stool/rectal swabs tested, 6035 (22.8%) specimens yielded V. cholerae. 4,046 (67%) of them were O1 serotype; followed by 1529 (25.3%) O139 serotype and 448 (7.4%) non-O1 serotypes other than O139 were encountered. Twelve specimens yielded rough strains of V. cholerae. All V. cholerae O1 were the biotype ElTor and the predominant serotype was Ogawa (95.9%). After the initial explosive epidemic by O139 serotype in late 1992 and early 1993 occurrence of this serotype had declined. Resurgence of this new serotype was observed in 1997. O1 domination was observed during 1995 and 1996. The new phage typing scheme for V. cholerae O1 was able to differentiate the isolates into 22 types, type 27 (68.2%) being the predominant one followed by type 26 (12.3%). In Basu & Mukerjee scheme, the isolates were clustered between two types--type 2 (34%) and type 4 (61%). Further, about 5 per cent of them were untypeable. All but a few of the isolates irrespective of serotype, were susceptible to chloramphenicol, tetracycline, gentamicin and ciprofloxacin. 97 per cent of the O1 strains and 48.9 per cent of the O139 strains were resistant to cotrimoxazole. INTERPRETATION & CONCLUSION: V. cholerae O139 might have the ability to survive during interepidemic periods. Both V. cholerae O1 and O139--the two serotypes with epidemic potential seem to be firmly established in this region. This situation warrants constant surveillance.

Distribution of phage type of Vibrio cholerae O1 biotype ElTor in Indian scenario (1991-98).

During the period 1991-98, distribution of biotype, serotype and phage type of V. cholerae O1 strains isolated from different parts of the country and referred to the National Institute of Cholera and Enteric Diseases, Calcutta were studied. Of the 8101 strains received, 5613 (69.2%) were subjected to phage typing. All these strains belonged to the biotype ElTor and Ogawa was the predominant serotype (96.08%). The strains were clustered into only two types--types 2 and 4 and around 10 per cent strains remained untypable. However, using the new scheme, all these strains were found to be typable and 8 major types were recognized of which type number 27 was the predominant type (66.12%). The distribution of a common type throughout the country suggests that a particular clone of V. cholerae O1 is probably circulating all over India. A constant monitoring through phage typing is necessary to observe the emergence of any new clone of V. cholerae O1 in India.

An El Tor cholera outbreak in Maldah district, West Bengal.

An outbreak of cholera occurred in Maldah district, West Bengal during July-August 1998. Attack rate was 34/1000. Cases were more (59.3%) amongst adults (> 15 years.). V. cholerae 01 biotype E1 Tor serotype ogawa was isolated as a single pathogen from 52.9% (9/17 samples examined). All V. cholerae strains belonged to phage type 2 (Basu and Mukherjee scheme) and type 27 (new phage type scheme). The strains were resistant to co-trimoxazole, furazolidone, ampicillin, streptomycin and nalidixic acid.

Multitransfused children with thalassemia major do not have gallstones.

Gall stones in children have been commonly described in hereditary spherocytosis and sickle cell anaemia. In North India thalassemia is the commonest haemolytic anaemia. We studied the incidence of gall stones sonographically in children with thalassemia major. Of the 64 multitransfused children with thalassemia major studied (age range 5-20 years) none had symptoms of biliary colic or evidence of gall stones on sonography. The study has demonstrated that patients with thalassemia major are not prone to develop gall stones.

Isolation of Vibrio cholerae 0139 phages to develop a phage typing scheme.

Five V. cholerae 0139 phages isolated from different parts of India have been used for phage typing study. A strain isolated from Nagpur city (NPR-4) was used as the host for phage propagation. All but one of the 260 strains of V. cholerae 0139 were found to be typeable and could be clustered into 8 distinct phage types as revealed by lytic patterns. Phage type 1 was the predominant type (61.15%) followed by type 2 (18.46%). The strains isolated from Madras exhibited 7 out of 8 phage types. These newly isolated phages could be adopted for phage typing of V. cholerae 0139 strains as an epidemiological tool.

Biological activity & interaction of Vibrio cholerae bacteriophages in rabbit ileal loop.

A set of ten V. cholerae EITor phages is in routine use for phage typing of V. cholerae O1 biotype EITor strains. These phages were used in rabbit ileal loop experiment to investigate whether these phages have any prophylactic value as regards their lytic capability on V. cholerae strains. The phages were found to have no prophylactic use as they were unable to lyse the standard bacterial strain V. cholerae MAK 757.

Polyarteritis nodosa--a few unusual findings.

OBJECTIVE: To report the clinical spectrum of polyarteritis nodosa (PAN) from North India and highlight some unusual findings. DESIGN: Retrospective study. SETTING: Hospital based. SUBJECTS: Eight children with PAN. INTERVENTION: Treatment with prednisolone and cyclophosphamide. RESULTS: One child had spontaneous remission while another started deteriorating rapidly in spite of treatment and died within 2 weeks. Six children went into remission-of these one died, two were lost to follow-up and the remaining three are on regular follow-up for periods ranging from 3-5 years. CONCLUSIONS: Prednisolone and cyclophosphamide can significantly improve the outcome in childhood PAN.