July effect in clinical outcomes of esophagogastroduodenoscopy performed at teaching hospitals in the United States.

Background: Esophagogastroduodenoscopy (EGD) is a common procedure used for both diagnosis and treatment, but carries risks such as bleeding and perforation. The "July effect"-described as increased complication rates during the transition of new trainees-has been studied in other procedures, but has not been thoroughly evaluated for EGD. Methods: We used the National Inpatient Sample database for 2016 to 2018 to compare outcomes in EGD performed between July to September and April to June. Results: Approximately 0.91 million patients in the study received EGD between July to September (49.35%) and April to June (50.65%), with no significant differences between the two groups in terms of age, gender, race, income, or insurance status. Of the 911,235 patients, 19,280 died during the study period following EGD, 2.14% (July-September) vs 1.95% (April-June), with an adjusted odds ratio of 1.09 (P < 0.01). The adjusted total hospitalization charge was $2052 higher in July-September ($81,597) vs April to June ($79,023) (P < 0.005). The mean length of stay was 6.8 days (July-September) vs 6.6 days (April-June) (P < 0.001). Conclusions: The results of this study are reassuring as the July effect on inpatient outcomes for EGDs was not significantly different according to our study. We recommend seeking prompt treatment and improving new trainee training and interspecialty communication for better patient outcomes.

Independent Risk Factors for Thromboembolic Events in High-Risk Patients With Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TCM) is characteristically associated with left ventricular apical ballooning and regional wall motion abnormalities that predispose to the formation of left ventricular (LV) thrombi and subsequent thromboembolic events (VTE). There is limited data about the risk factors of developing stroke in the absence of LV thrombi in patients with TCM. Identify risk factors that predispose patients with TCM to develop VTE and stroke. We retrospectively reviewed all patients admitted with a primary diagnosis of stress induced or Takotsubo cardiomyopathy at a large tertiary care center from 2005 to 2019. Patients who met the echocardiographic criteria of TCM, had resolution of WMA on repeat echocardiogram, did not have coronary artery disease if angiography was performed and survived for > 3 months after index presentation were included in the analysis. Patients were followed for up to a period of 1 year. Multivariate analysis was performed to identify predictors of thromboembolism. Among the 400 patients who presented with TCM, 146 patients were included in the analysis. A total of 13 patients (8.9%) had documented thromboembolic events. Patients with VTE more often had Atrial fibrillation (30.8% vs 6.8%, P = 0.018), higher LV mass (224.5g vs 184g, P = 0.04), lower EF on presentation (31.5% vs 40%, P = 0.011) and were less likely to have undergone coronary angiography following diagnosis (23.1% vs 54.9%, P = 0.04). On multivariate analysis, atrial fibrillation (OR 9.15, CI 1.15-72.70) and low ejection fraction on admission (OR 0.88, CI 0.81-0.97) were independent risk factors for the development of VTE. Atrial fibrillation and low ejection fraction on presentation were associated with higher risk of developing thromboembolic events in patients with TCM.

The first study of epidemiology of adolescent idiopathic scoliosis shows lower prevalence in females of Jammu and Kashmir, India.

AIS is a heterogeneous 3D spinal deformity with Cobb angle ≥10°. It affects children in the age group of 10-16 years globally with 2-3% prevalence and significant female predominance. The exact etiology of AIS is not known however, it is supposed to be associated with factors such as anthropometric, metabolic, neuromuscular abnormalities and genetics. OBJECTIVES: To determine the prevalence of AIS and association of anthropometric factors with AIS in the studied population group. METHODOLOGY: Scoliosis screening of 9,500 individuals was carried out at different educational institutions of Jammu region in Jammu and Kashmir, India using a scoliosis-meter. The subjects were later examined radiologically. RESULTS: In population of the region, AIS was most prevalent among all types of scoliosis with overall prevalence of 0.61%. The prevalence was observed to be lower in females (0.31%) than males (0.88%). Based on angle of trunk rotation (ATR), lumbar curves were more prevalent than thoracic curves. Average Cobb angle in males and females were 24.9° and 22.6°, respectively. BMI showed significant association with AIS in the age group of 12-16 years (P value =0.028). Furthermore, height was significantly associated with AIS in the overall screened population (P-value =0.029). CONCLUSIONS: The AIS patients in the Jammu region of India have unique clinical features. In contrast to the global prevalence data, the prevalence of AIS in females in the region was less in comparison to males. Based on epidemiological literature and our findings, we hypothesized that genetic factors might be a major contributor in the AIS pathogenesis along with other confounding factors such as height, BMI, ethnicity, etc.

Non-Convulsive Status Epilepticus in Hepatic Encephalopathy: A Case Series and Review of the Literature.

Hepatic encephalopathy is a common complication in chronic liver disease and cirrhosis. Here we describe two patients with hepatic encephalopathy who did not respond to standard empiric treatment and were found to have non-convulsive status epilepticus. Both patients improved with antiepileptic therapy. Non-convulsive status epilepticus should be considered in the differential diagnosis of patients with suspected hepatic encephalopathy who do not respond to empiric treatment. LEARNING POINTS: Non-convulsive status epilepticus (NCSE) is a rare complication of hepatic encephalopathy (HE).Clinical evaluation should be used to rule out different causes of altered mental status in patients with chronic liver disease.Consider EEG to diagnose NCSE in patients with suspected HE not responding to empiric treatment.

Determination of Non-Recrystallization Temperature for Niobium Microalloyed Steel.

In the present investigation, the non-recrystallization temperature (TNR) of niobium-microalloyed steel is determined to plan rolling schedules for obtaining the desired properties of steel. The value of TNR is based on both alloying elements and deformation parameters. In the literature, TNR equations have been developed and utilized. However, each equation has certain limitations which constrain its applicability. This study was completed using laboratory-grade low-carbon Nb-microalloyed steels designed to meet the API X-70 specification. Nb- microalloyed steel is processed by the melting and casting process, and the composition is found by optical emission spectroscopy (OES). Multiple-hit deformation tests were carried out on a Gleeble® 3500 system in the standard pocket-jaw configuration to determine TNR. Cuboidal specimens (10 (L) × 20 (W) × 20 (T) mm3) were taken for compression test (multiple-hit deformation tests) in gleeble. Microstructure evolutions were carried out by using OM (optical microscopy) and SEM (scanning electron microscopy). The value of TNR determined for 0.1 wt.% niobium bearing microalloyed steel is ~ 951 °C. Nb- microalloyed steel rolled at TNR produce partially recrystallized grain with ferrite nucleation. Hence, to verify the TNR value, a rolling process is applied with the finishing rolling temperature near TNR (~951 °C). The microstructure is also revealed in the pancake shape, which confirms TNR.

Acute Myeloid Leukemia: Is That All There Is?

Acute myeloid leukemia (AML) is characterized by the clonal proliferation of malignant myeloid blast cells in the marrow along with impaired normal hematopoiesis. With an almost stagnant approach for the management of patients with AML in the last three decades, the main purpose of this paper is to increase our understanding of recent scientific advancements for the enhanced diagnosis and treatment of AML. Existing research data related to different approaches for a possible improvement in AML management has been collected and discussed. The identification of recurrently mutated genes, such as CCAAT-enhancer-binding proteins α (CEBPα), Fms-related tyrosine kinase 3 (FLT3), and nucleophosmin 1 (NPM1) along with the classic diagnostic karyotype has improved prognostic-risk stratification. Moreover, mutations affecting cellular metabolism like isocitrate dehydrogenase (IDH1), lysine-specific demethylase 1 (LSD 1), and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) have become a huge success by providing targets for novel therapeutic drugs. Checkpoint inhibitors (CPI) and vaccination against tumor-associated antigen are added options considered, which require further trials before their efficacy can be determined. An important tool in monitoring early response to therapy, minimal residual disease (MRD) assays can be further refined by including pretreatment parameters such as cytogenetic and molecular markers. Potential side effects and resistance to treatment remains a huge barrier in completely finding success against AML and work needs to be done to find combinations of immunotherapies to possibly reduce adaptive resistance by AML.

Metastatic Castration-Resistant Prostate Cancer Previously Treated With Docetaxel-Based Chemotherapy: Treatment Patterns From the PROXIMA Prospective Registry.

PURPOSE: There is a major clinical need to devise an optimal treatment sequence for the multiple therapy options available for patients with metastatic castration-resistant prostate cancer (mCRPC). In the absence of prospective clinical trials, sequencing information can be derived from large, real-world registry studies. PATIENTS AND METHODS: PROXIMA (Treatment Patterns in Patients With Metastatic Castration-Resistant Prostate Cancer Previously Treated With Docetaxel-Based Chemotherapy) is a large, global, prospective registry study evaluating real-world treatment patterns of patients with mCRPC who experience disease progression during or after docetaxel therapy. Patients were enrolled worldwide between 2011 and 2014. Treatments were determined by the treating physicians and recorded in categories of chemotherapy, hormonal therapy, targeted therapy, immunotherapy, and palliative therapy. Treatment sequencing patterns, response to treatment, and types of progression were recorded and analyzed. Progression-free survival and overall survival with different treatment modalities were analyzed using Kaplan-Meier method. RESULTS: Treatment patterns were evaluated in 903 patients. Therapy selection was influenced by region. Hormonal therapy (57.5%) and taxane chemotherapy (26.4%) were the most frequently administered first subsequent treatments after docetaxel. Tumor responses to first subsequent treatment were observed in 22.6% of evaluable patients. Overall survival and progression-free survival did not differ significantly across different treatment modalities. CONCLUSION: Identifying an optimal treatment sequence is vital for improving the care of patients with mCRPC. The PROXIMA registry provided a representative sample of global data on real-world treatment patterns for patients with mCRPC previously treated with docetaxel. These data can be used to devise optimal therapy sequences and inform treatment decisions.

Comparison of Nottingham Prognostic Index and Adjuvant Online prognostic tools in young women with breast cancer: review of a single-institution experience.

OBJECTIVE: Accurately predicting the prognosis of young patients with breast cancer (<40 years) is uncertain since the literature suggests they have a higher mortality and that age is an independent risk factor. In this cohort study we considered two prognostic tools; Nottingham Prognostic Index and Adjuvant Online (Adjuvant!), in a group of young patients, comparing their predicted prognosis with their actual survival. SETTING: North East England PARTICIPANTS: Data was prospectively collected from the breast unit at a Hospital in Grimsby between January 1998 and December 2007. A cohort of 102 young patients with primary breast cancer was identified and actual survival data was recorded. The Nottingham Prognostic Index and Adjuvant! scores were calculated and used to estimate 10-year survival probabilities. Pearson's correlation coefficient was used to demonstrate the association between the Nottingham Prognostic Index and Adjuvant! scores. A constant yearly hazard rate was assumed to generate 10-year cumulative survival curves using the Nottingham Prognostic Index and Adjuvant! predictions. RESULTS: Actual 10-year survival for the 92 patients who underwent potentially curative surgery for invasive cancer was 77.2% (CI 68.6% to 85.8%). There was no significant difference between the actual survival and the Nottingham Prognostic Index and Adjuvant! 10-year estimated survival, which was 77.3% (CI 74.4% to 80.2%) and 82.1% (CI 79.1% to 85.1%), respectively. The Nottingham Prognostic Index and Adjuvant! results demonstrated strong correlation and both predicted cumulative survival curves accurately reflected the actual survival in young patients. CONCLUSIONS: The Nottingham Prognostic Index and Adjuvant! are widely used to predict survival in patients with breast cancer. In this study no statistically significant difference was shown between the predicted prognosis and actual survival of a group of young patients with breast cancer.

Sequential maximum androgen blockade (MAB) in minimally symptomatic prostate cancer progressing after initial MAB: two case reports.

The management of castrate-resistant prostate cancer progressing after maximum androgen blockade (MAB) has evolved in the last decade with the development of several novel therapeutic options. However, the initial therapeutic strategy in these patients usually involves withdrawal of anti-androgen that can be associated with biochemical response in approximately 20% of patients. Notably, we have observed evidence of sustained biochemical response in two patients following second- and third-line MAB using rechallenge schedule of previously administered anti-androgen after latent interval. The possibility of response following sequential MAB using the same anti-androgen agent has not yet been reported.

Evolution of the treatment paradigm for patients with metastatic castration-resistant prostate cancer.

As recently as 2004, treatment options for men with metastatic castration-resistant prostate cancer (mCRPC) were limited, with docetaxel the only approved agent conferring a survival benefit. The therapeutic landscape is now very different, with several agents demonstrating prolonged survival since 2010. New agents for the treatment of mCRPC include sipuleucel-T, cabazitaxel, abiraterone acetate, enzalutamide and radium-223. All are now approved for use in this patient group, although the specific licensing terms vary between agents. In addition, denosumab may have utility in patients with bone metastases. A number of novel agents are also in development with promising initial results. However, because these treatment options have proliferated rapidly, there is currently a paucity of clinical evidence regarding their optimal sequencing. Selection of an appropriate treatment option should take into consideration disease characteristics, drug availability and patient choice. In summary, we discuss several new treatment options available for mCRPC and their integration into the current treatment paradigm.

The posterior to anterior controlled technique of percutaneous Achilles tenotomy in the correction of idiopathic clubfoot: a technical report.

Percutaneous tenotomy of the Achilles tendon is an integral part of the Ponseti technique of clubfoot correction. Although originally described by Ponseti as an office procedure that was performed under local anaesthesia, serious neurovascular complications that include iatrogenic injury to the lesser saphenous vein, the posterior tibial neurovascular bundle, the sural artery and pseudoaneurysm formation have been reported. We describe a new tenotomy technique, the posterior to anterior controlled technique, that may decrease the possibility of neurovascular damage, does not require exposure of the Achilles tendon and can be performed as an office procedure under local anaesthesia.

A case of limbic encephalitis presenting as a paraneoplastic manifestation of limited stage small cell lung cancer: a case report.

INTRODUCTION: The differential diagnosis of altered mental status and behavioral change is very extensive. Paraneoplastic limbic encephalitis is a rare cause of cognitive impairment, which should be considered in the differential diagnosis. CASE PRESENTATION: A 64-year-old British Caucasian woman presented to our hospital with a 12-week history of confusion and short-term memory loss. She was hyponatremic with a serum sodium level of 128mmol/L. Moreover, there was evidence of left hilar prominence on the chest radiograph. A thoracic computed tomography scan showed left hilar opacity with confluent lymphadenopathy. A percutaneous biopsy confirmed a diagnosis of small cell lung cancer. There was no radiological evidence of brain metastasis on the computed tomography scan. In view of continued cognitive impairment, which was felt to be disproportionate to hyponatremia, a magnetic resonance imaging scan of the brain was undertaken. It showed hyperintense signals from both hippocampi, highly suggestive of limbic encephalitis presenting as a paraneoplastic manifestation of small cell lung cancer. She had a significant radiological and clinical response following chemotherapy and radiotherapy. CONCLUSION: This case highlights the importance of considering paraneoplastic syndromes in patients with neurological symptoms in the context of lung malignancy. If initial investigations fail to reveal the cause of cognitive impairment in a patient with malignancy, magnetic resonance imaging may be invaluable in the diagnosis of limbic encephalitis. The clinical presentation, diagnostic techniques and management of paraneoplastic limbic encephalitis are discussed in this case report.

Lateral invaginating peg (LIP) osteotomy for the correction of post-traumatic cubitus varus deformity.

Closing wedge osteotomies are the gold standard for the management of post-traumatic cubitus varus deformity. However, most of these osteotomies are fraught with complications such as lateral condylar prominence, instability, and difficulty in correcting internal rotation. We describe a new technique that provides a means for the management of all these problems simultaneously.

Complications of paediatric elbow trauma treatment by traditional bonesetters.

This is a retrospective review of paediatric elbow trauma, which was initially treated by bonesetters and subsequently reported to the hospital for management. This paper describes the pattern of trauma and the complications of unscientific management. The report also recommends a basic training program for the bonesetters so as to make them aware of the potential complications involved in managing paediatric elbow trauma.

Outcome of treatment of the mismanaged pediatric elbow trauma: a series of 73 cases.

PURPOSE: To analyze the outcome of the management of pediatric elbow trauma referred to our hospital after initial intervention by traditional bone setters. METHOD: Retrospective study of 73 patients, presenting to the hospital with a complication attributable to the initial mismanagement of their injuries. RESULTS: The mode of presentation was directly related to the type of initial intervention on the basis of which we were able to quantify bone setters into two groups. The first group using a rather rough method of trauma treatment involving the application of tight local bandages, massage and manipulation and a second group having a relatively less rough approach, applying splints to the injured extremity without tight bandages and manipulation. The result of treatment of these injuries was determined by the delay in presentation and the type of injury. CONCLUSION: This study highlights the importance of dealing with the unchecked and unsupervised practice of bone setting in the developing world. We believe that training these people on the pattern of traditional birth attendants can at the very least lower the occurrence, if not entirely eliminate the problem of mismanaged trauma in this part of the world.