Ozone disc nucleolysis in the management of herniated lumbar intervertebral disc: A retrospective analysis.

Background: Various minimally invasive surgeries were proposed for the management of herniated lumbar intervertebral disc. However, to choose optimal treatment modality to maximize patient benefit is a clinical challenge for the treatment givers. Objective: The objective was to study the role of ozone disc nucleolysis in the management of herniated lumbar intervertebral disc by retrospective analysis. Methodology: We conducted a retrospective analysis of patients of lumbar disc herniation treated by ozone disc nucleolysis during May 2007-May 2021. There were total of 2089 patients with 58% of males and 42% of females. The age ranged from 18 to 88 years. Outcome was measured on the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) along with modified MacNab method. Results: The mean baseline VAS score was 7.73, which became 3.07 at 1 month, 1.44 at 3 months, 1.42 at 6 months, and 1.36 at 1 year. Similarly, the mean ODI index was 35.92 at baseline, which improved to 9.17 at 1 month, 6.14 at 3 months, 6.10 at 6 months, and 6.09 at 1 year. VAS score and ODI analysis was found to be statistically significant with P < 0.05. Modified MacNab criterion showed successful treatment outcome in 85.6% with excellent recovery in 1161 (55.58%), good recovery in 423 (20.25%), and fair recovery in 204 (9.77%). Mediocre or no recovery was seen in the remaining 301 patients amounting to a 14.40% failure rate. Conclusion: This retrospective analysis confirms that ozone disc nucleolysis is an optimally effective and least invasive treatment option for herniated lumbar intervertebral disc with a significant reduction in disability.

Severe Ulcerative Colitis as a Complication of Mild COVID-19 Infection in a Vaccinated Patient.

Prior studies have proposed a direct correlation between the severity of coronavirus disease 2019 (COVID-19) and the severity of ulcerative colitis (UC). This is explained by an autoimmune response from molecular mimicry or via angiotensin-converting enzyme 2 receptor. However, we present a novel case of an inverse correlation between asymptomatic COVID-19 causing severe UC. An 84-year-old male with prior infectious colitis and asymptomatic COVID-19 presented with septic shock secondary to presumed infectious colitis. Blood workup suggested inflammatory bowel disease, which was confirmed to be UC via flexible sigmoidoscopy and pathology. He was managed successfully with oral mesalamine and high-dose intravenous steroids, which were later transitioned to an oral taper. This case reflects that the intensity of the impact of COVID-19 on the gastrointestinal system can be as variable as the immune system reaction in an already labile environment such as in the elderly and malnourished patients. Therefore, in view of a lack of reports establishing a relationship between these two entities, we aim to report a case and propose an association between mild or asymptomatic COVID-19 and severe UC.

Ozone disc nucleolysis in cervical intervertebral disc herniation: A nonrandomized prospective analysis in 246 patients.

Background: Inherent complications associated with surgery and limited success of percutaneous minimally invasive procedures make researches wanting for an ideal treatment for cervical disc herniation. Objective: We prospectively study the role of ozone disc nucleolysis in cervical intervertebral disc herniation. Patients and Methods: From January 2008 to December 2020, we prospectively study 246 consecutive patients of cervical disc herniation treated by a single session of intradiscal injection of ozone-oxygen mixture (ozone disc nucleolysis). There were 55% of females and 45% of males. Age ranged from 28 to 68 years with a mean of 47. The outcome was measured on visual analog scale (VAS) scale and neck disability index (NDI) along with Mcnab method. Results: The mean baseline VAS score was 7.87 which became 3.09 at 1 month, 1.42 at 3 months, 1.40 at 6 months, and 1.35 at 1 year. The mean NDI was 36.27 at baseline which improved to 9.24 at 1 month, 6.25 at 3 months, 6.20 at 6 months, and 6.22 at 1 year. This was found to be significant with P < 0.05. Modified McNab criterion showed excellent recovery in 138 (56.10%), good recovery in 50 (20.32%), and fair recovery in 22 (8.94%), resulting in a successful rate of 85.36%. Mediocre recovery was seen in the remaining 36 patients amounting to a 14.64% failure rate. Conclusion: This study showed that ozone disc nucleolysis significantly reduces the pain related to cervical disc herniation along with a significant reduction in disability.

Correlation of Severity of COVID-19 Disease With Gastrointestinal Manifestations and Liver Injury - A North Brooklyn Community Hospital Experience: A Retrospective Cohort Study.

Introduction The primary receptor for SARS-CoV-2 infection, angiotensin-converting enzyme-2 (ACE-2), is expressed in the gastrointestinal tract and liver parenchyma. The involvement of the gastrointestinal tract with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection has remained unclear. The following study retrospectively reviews gastrointestinal symptoms and liver function tests at the time of hospital admission to identify patient outcomes including prolonged hospital stay, the requirement for intensive care, and all-cause in-hospital 30-day mortality. Methods A retrospective review of patient charts at the Woodhull Medical and Mental Health Center (WMC) was conducted at the time of hospital admission, using a pre-determined selection criterion. All adult patients, both inpatient and outpatient, were included from March 2020 till May 2020. A 95% confidence interval was used to estimate the odds ratio (OR) for patient outcomes. Results Of the 520 patients, gastrointestinal symptoms including nausea (OR = 0.375, p = 0.015), and nausea and vomiting in combination (OR = 0.400, p = 0.016) had an inverse protective relationship with all-cause in-hospital 30-day mortality among COVID-19 patients. Gastrointestinal symptoms including diarrhea (OR = 1.008, p < 0.001), and nausea and vomiting (OR = 1.291, p = 0.043) had a mild impact on the length of hospital stay. Conclusion Elevated liver transaminases including alanine transaminase (ALT) and aspartate transaminase (AST) at the time of hospital admission can predict critical care requirement and all-cause 30-day hospital mortality in patients with COVID-19 infection. Presence of gastrointestinal symptoms is associated with worsened outcomes.

A Rare Cause of Recurrent Lower Gastrointestinal Bleed: Colonic Dieulafoy's Lesion.

Dieulafoy's lesion accounts for 1%-2% of acute gastrointestinal (GI) bleeding cases, and approximately 2% of Dieulafoy's lesions are present in the colon. We report the case of an 83-year-old female who presented with recurrent gastrointestinal bleeding from colonic Dieulafoy's lesion located at the hepatic flexure. She initially presented four weeks prior with melena in the setting of Eliquis use for venous thrombosis, coronary artery disease, and end-stage renal disease. Upper endoscopy revealed esophagitis, gastritis, and duodenitis. Diagnostic colonoscopy and video capsule endoscopy both revealed blood in the colon without an identifiable source. During the second admission for recurrent melena with hemoglobin of 3.9 g/dL, Eliquis was discontinued, and the patient was resuscitated with three units of packed red blood cell transfusions. Repeat colonoscopy revealed a pulsating vessel with active oozing located at the hepatic flexure, consistent with a Dieulafoy's lesion. Hemostatic endoclips and bipolar electrocautery were applied to achieve complete hemostasis. Colonic Dieulafoy's lesions, albeit rare, should be considered in patients presenting with an acute obscure lower GI bleed. Primary hemostasis can be achieved with several endoscopic modalities including epinephrine, hemoclipping, thermocoagulation, or sclerotherapy.

Nasal Spray Use Technique Among Patients Attending the Out-Patient Department of a Tertiary Care Hospital, Gandaki Province, Nepal.

BACKGROUND: Nasal sprays are used to deliver the medications locally to the nasal cavity. The majority of patients have been observed to perform nasal spray use techniques inadequately. This study was conducted to evaluate the impact of the intervention on nasal spray use technique. METHODS: This was a prospective pre- and post-interventional study to evaluate the nasal spray use technique among the subjects with the help of nasal spray checklist. A standardized WHO nasal spray checklist was used on the study conducted in Manipal Teaching Hospital, Pokhara, Nepal from July to October 2019. Subjects were asked to demonstrate the technique and a scoring system was applied before and after the intervention by the researcher. The total score of the intervention technique ranges from 0 to 11. After evaluation of the technique at the first visit, subjects were provided with an informative leaflet having all the steps to be followed to use the spray and the technique was re-evaluated after 10 days. RESULTS: A total of 81 subjects (51.9% male and 48.1% female) participated in the study. The average duration of nasal drug use was 15 days. The overall mean±SD score was 4.31±1.625 before intervention and 9.84±1.699 after intervention. After the intervention, the percentage of subjects using the nasal spray correctly increased by 50.27%. Wilcoxon signedrank test showed intervention on nasal spray use technique was effective (p=0.0001). CONCLUSION: The nasal spray use technique was poor among the subjects before the intervention. The intervention was substantially effective in improving the technique to use the nasal spray. Regular assessment and reinforcement of correct technique by health professionals will improve the proper use technique of nasal spray, hence increasing the effectiveness of the therapy.

Dual stimuli-responsive ursolic acid-embedded nanophytoliposome for targeted antitumor therapy.

The hindrances in achieving clinically translatable anticancer platforms are being tackled through nanotechnology-based formulations. In this study, stimuli-responsive, phytoactive constituent-loaded nanophytoliposomes were fabricated for designing a specific antitumor platform. Ursolic acid (UA)-loaded nanophytoliposomes (UA-PLL-HA.P) enwrapped in a poly-L-lysine (PLL) coat and hyaluronic acid (HA) were nanosized; these nanophytoliposomes had spherical morphology, slightly negative charge, and an in-range polydispersity index (~0.25). Successful fabrication of the nanosystem was proven through several characterization methods and the pH- and enzyme-responsiveness of the nanosystem was assessed through a release study. The cellular internalization in CD44 receptor-expressing cell lines was amplified by enhanced permeation and retention as well as by active targeting. In vitro antitumor behavior was confirmed through in vitro cytotoxic and apoptotic activity of the nanosystem. Similarly, in vivo imaging showed exceptional biodistribution in the tumor in agreement with the in vitro findings. Moreover, the tumor inhibitory rate of UA-PLL-HA.P was significantly higher, and was ascribed to the targeting potential and stimuli-responsiveness. In summary, UA-PLL-HA.P exhibited pronounced anticancer effect and could open a number of possibilities for discovering novel phytoconstituent-incorporated nanoformulations.

EEG Findings in Infants With Neonatal Abstinence Syndrome Presenting With Clinical Seizures.

Neonatal abstinence syndrome (NAS) refers to a constellation of signs occurring in newborn infants who were exposed to opioids or opiates in utero. These manifestations include poor feeding, gastrointestinal disorders, abnormal sleep patterns, and neurological signs such as jitteriness, tremors, and seizures (1, 2). Myoclonus, jitteriness, and tremors often may be interpreted as seizures and therefore treated as epileptic seizures. Objective: To determine whether seizure like activity observed in infants with NAS correlate with electroencephalogram (EEG) findings. Design/ Method: We reviewed the standard EEG or video electroencephalogram (VEEG) of infants with NAS who were admitted because of seizure-like clinical activity. The exclusion criteria were major neurological anomalies, hypoxic ischemic encephalopathy, metabolic disorders, or with clinical diagnosis other than NAS. Results: Forty neonates met study criteria; 28 had standard EEG recordings and 18 had VEEG. Mean gestational age was 38.5 weeks. The onset of seizure-like clinical activity was as early as day 1 and as late as day 16 of life. The clinical seizure-like activity described at the referring hospital were jerking, rhythmic movement of the extremities, or tremors. Only three (7.5%) neonates had epileptic seizures. There were increased sharp transients in frontal, central, temporal, and or occipital regions. VEEG showed disturbed non-rapid eye movement (REM) sleep with frequent arousal, jittery movements, or sleep myoclonus. Conclusion: Clinical seizure-like activity correlates poorly with epileptic seizures in infants with NAS. In neonates with NAS, a VEEG would be useful to determine if the clinical seizure-like activity is of epileptic origin or not, prior to initiation of anti-seizure medications.

Diagnostic yield of capsule endoscopy for small bowel arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia: a systematic review and meta-analysis.

Background and study aims Small bowel arteriovenous malformations (AVMs) pose a bleeding risk and have traditionally been diagnosed by invasive enteroscopic procedures in patients with hereditary hemorrhagic telangiectasia (HHT). Capsule endoscopy (CE) is emerging as a safe and non-invasive alternative for small intestinal evaluation, but its diagnostic yield and utility in diagnosing small bowel AVMs in HHT patients are understudied. The aim of this study was to meta-analyze the utility of CE for diagnosing AVMs in HHT patients. Methods A meta-analysis and systematic review of the literature on CE in HHT patients identified in the PubMed, EMBASE, Scopus, and Cochrane databases from inception to March 2018 were conducted. Summary effects were estimated using a random effects model. Results After applying exclusion criteria, five studies (n = 124 patients) were eligible for meta-analysis. The pooled diagnostic yield for visualization of small bowel AVMs by CE was 77.0 % (95 % CI 65.8 - 85.4 %, P  < 0.001). Conclusions CE has a good diagnostic yield for small bowel AVMs in HHT. It can be regarded as a sufficient, noninvasive diagnostic modality for identifying small bowel AVMs in HHT patients.

Antiphospholipid syndrome presenting as acute mesenteric venous thrombosis involving a variant inferior mesenteric vein and successful treatment with rivaroxaban.

Acute mesenteric venous thrombosis (MVT) is the rarest cause of acute mesenteric ischaemia, so thrombosis of a variant inferior mesenteric vein (IMV) is especially uncommon in the setting of antiphospholipid syndrome (APS). Here, we present such a case of seronegative APS initially manifesting as an anomalous IMV thrombosis in a 76-year-old woman. Although guidelines support anticoagulation with vitamin K antagonists in these patients, we anticoagulated with rivaroxaban (a direct oral anticoagulant (DOAC)) due to patient preference, which resulted in complete clinical and endoscopic resolution. IMV thrombosis is a rare form of MVT, only two case reports describe successful anticoagulation with DOACs in the setting of MVT and none report APS as an underlying aetiology. Therefore, this case provides the opportunity to review the pathophysiology of MVT, APS and their medical management including current trends in anticoagulation.

Brain tumors associated with psychogenic non-epileptic seizures: Case series.

OBJECTIVE: The association of psychogenic non-epileptic seizures (PNES) with primary or secondary brain tumors has not been well described in the literature. We aim to discuss their association, and their impact in brain tumor treatment. PATIENTS AND METHODS: We identified four patients retrospectively from our practice. The diagnosis of PNES was based on clinical suspicion and standard EEG, supplemented with video-EEG recording in 2 patients. RESULTS: The initial diagnosis of brain tumor was associated with a new onset seizure prior to diagnosis. The majority of the patients presented with ES followed by recurrent PNES during the course of their disease. Patients were treated with multiple anti-epileptic drugs, requiring frequent schedule adjustments. The preferred tumor treatment modality was chemotherapy, followed by surgical resection. The patients were offered psychological consultation achieving partial control of their events. These patients manifested recurrent disabling clinical events that required multiple medical consultations. None of these patients presented clinical evidence of tumor progression at the time of PNES presentation. CONCLUSION: A high index of suspicion and early psychological consultation referral will likely mitigate the quality of life impact of PNES in these patients.

Disease proportions and drug prescribing pattern observed in a free health camp organized at Dhorphirdi Village Development Committee of Western Nepal.

BACKGROUND: Health camp is generally organized to provide health care services to the people deprived of health care facilities. The aim of this project was to assess the proportions of disease among attendees of health camp and study the drug prescribing pattern in a free health camp. METHODS: A case study was performed from 1 day health camp to determine the proportions of disease and drug prescribing pattern. Data collection was performed using log book maintained in the health camp and patient's demographic details, disease diagnosed and drug prescribed was obtained from same log book. RESULTS: A total of 317 patients were included in the study. The majority of the patients were in the range of 41-50 years. On the basis of study on ethnicity, Brahmins and Chettris, were found to be predominant ethnic groups with gastrointestinal disorders as the major disease. The total number of medications prescribed was 510, with non-steroidal anti-inflammatory drugs (NSAIDs) and antipeptic ulcer drugs being commonly prescribed. The average number of drugs per prescription and the percentage of antibiotics prescribed were 1.6 and 21.4%, respectively. It was observed that 96.8% of prescription was by generic names. Likewise, 100% of prescription included drugs from essential drug list. CONCLUSION: Majority of the patients were of working age group. Headache and fever were found to be the most prevalent cases and NSAIDs were the most commonly prescribed medications. The drug prescribing pattern of the free health camp complied with WHO recommended prescribing indicators.

Evaluation of anti-secretory and anti-ulcerogenic activities of avipattikar churna on the peptic ulcers in experimental rats.

BACKGROUND: Avipattikar churna, a poly-herbal formulation, is one of the popular ayurvedic formulations which is used for peptic ulcer diseases but the scientific documentation with regards to its effect for the indication is lacking. AIMS: This study was carried out to evaluate the anti-secretory and the anti-ulcerogenic activities of the churna and to compare its activity with that of ranitidine in a pyloric ligated model of rats. MATERIAL AND METHODS: Four groups of rats with 6 animals in each served as the ulcer controls, churna low dose (500 mg/kg), churna high dose (750mg/kg) and ranitidine (25mg/kg). The control group rats received only vehicle (2% (v/v) gum acacia), while the rats of the other groups received the respective dose of the churna or ranitidine which was suspended in the vehicle. The treatments were given twice a day, orally, for two days. After 1 hour of the last dose, pyloric ligations were performed and the rats were sacrificed for evaluation after four hours of the ligations. The gastric contents were collected and its volume, pH and acidity were measured. The numbers of ulcers and their lengths were measured which were used to calculate the gastric irritancy index and the curative ratio. The histological examinations of the gastric tissues were also performed. RESULTS: The churna, in both doses, significantly decreased the volumes of the gastric contents, the ulcer score, the length of the ulcer, the gastric irritancy index and pH increased as compared to those in the control group. The effects of the churna were comparable to that of ranitidine. The histopathological evaluation of the gastric tissue also supported the results. CONCLUSION: Avipattikar churna has anti-secretory and anti-ulcerogenic effects which are comparable to those of ranitidine in peptic ulcer diseases.

Isolated Histoplasma capsulatum meningoencephalitis in an immunocompetent child.

Histoplasmosis with central nervous system involvement typically arises in the immunocompromised patient with disseminated fungal disease. Rarely, neurologic histoplasmosis may arise as an isolated syndrome in immunocompetent individuals without evidence of general dissemination. The disease often is diagnostically challenging, and a high index of suspicion is required for diagnosis. We describe an immunocompetent 13-year-old girl with atypical symptoms and unusual radiologic findings due to laboratory-confirmed histoplasma meningoencephalitis. She responded well to antifungal therapy.