Thyroid Storm: Clinical Manifestation, Pathophysiology, and Treatment

Thyroid storm is a rare but life-threatening endocrine emergency. It is an acute exaggerated clinical manifestation of thyrotoxic state. The exact incidence is unknown. It occurs in 1–2% of patients admitted for thyrotoxicosis. It has a mortality of 10–20%. This chapter would help us to understand its clinical manifestations, pathophysiology, and effective treatment. Terminal learning objective would be to diagnose impending storm early and start prompt treatment in day-to-day practice. The chapter would cover pathophysiology including triggers, clinical features including various diagnostic criteria, diagnosis, and treatment of thyroid storm. Indications of surgical treatment in storm will be discussed

Curse of the technology-computer related musculoskeletal disorders and vision syndrome: a study

Background: Computer Related Musculoskeletal disorders and Vision Syndrome (CRMSKVS) is defined as symptoms due to prolonged use of Visual Display Terminal (VDT).Methods: A cross-sectional observational study was done among office-workers working on computer terminal. A self-reported questionnaire was distributed and Musculoskeletal (MSK) and visual symptoms in the preceding 12 months (01 October 2017 to 30 September 2018) were taken as dependent variable. Multivariate analysis was done to identify the determinants of CRMSKVS.Results: Responses from 1193 subjects were included in the study. CRMSKVS was present in 489 cases (40.98%; males - 37.5%, females - 58.29%).  The main MSK symptoms were pain/stiffness in neck (40.98%), shoulder (38.99%), lower back (35.6%) and elbow/wrist/hand/fingers (23.1%). The ocular symptoms were excessive watering (39.6%), pain (24.99), irritation (18.6%), burning/itching sensation (29.8%), redness (40.7%), blurring of vision (13.2%) and headache (40.9%). Female gender (OR-1.498(1.262-1.778)), long duration of working hours (OR-2.77(2.399-3.214)), poor break duration (OR-2.59(2.172-3.089)), excessive smart phone use (OR-2.071(1.834-2.338)), poor posture (OR-3.883(3.282-4.592)), inappropriate distance of computer screen (OR-2.173(1.829-2.582)), low height of screen (OR-1.936(1.527-2.454)), distance of keyboard (OR-3.161(2.528-3.953)) and distance of mouse (OR-5.785(3.932-8.512)) were identified as significant determinants of CRMSKVS.Conclusions: CRMSKVS is an emerging pandemic which needs urgent attention by medical and administrative authorities. The device factors, personal factors, environmental and ergonomic factors are the modifiable risk factors for CRMSKVS

Contribution of germline BRCA1 and BRCA2 sequence alterations to breast cancer in Northern India

BACKGROUND: A large number of distinct mutations in the BRCA1 and BRCA2 genes have been reported worldwide, but little is known regarding the role of these inherited susceptibility genes in breast cancer risk among Indian women. We investigated the distribution and the nature of BRCA1 and BRCA2 germline mutations and polymorphisms in a cohort of 204 Indian breast cancer patients and 140 age-matched controls. METHOD: Cases were selected with regard to early onset disease (≤40 years) and family history of breast and ovarian cancer. Two hundred four breast cancer cases along with 140 age-matched controls were analyzed for mutations. All coding regions and exon-intron boundaries of the BRCA1 and BRCA2 genes were screened by heteroduplex analysis followed by direct sequencing of detected variants. RESULTS: In total, 18 genetic alterations were identified. Three deleterious frame-shift mutations (185delAG in exon 2; 4184del4 and 3596del4 in exon 11) were identified in BRCA1, along with one missense mutation (K1667R), one 5'UTR alteration (22C>G), three intronic variants (IVS10-12delG, IVS13+2T>C, IVS7+38T>C) and one silent substitution (5154C>T). Similarly three pathogenic protein-truncating mutations (6376insAA in exon 11, 8576insC in exon19, and 9999delA in exon 27) along with one missense mutation (A2951T), four intronic alterations (IVS2+90T>A, IVS7+75A>T, IVS8+56C>T, IVS25+58insG) and one silent substitution (1593A>G) were identified in BRCA2. Four previously reported polymorphisms (K1183R, S1613G, and M1652I in BRCA1, and 7470A>G in BRCA2) were detected in both controls and breast cancer patients. Rare BRCA1/2 sequence alterations were observed in 15 out of 105 (14.2%) early-onset cases without family history and 11.7% (4/34) breast cancer cases with family history. Of these, six were pathogenic protein truncating mutations. In addition, several variants of uncertain clinical significance were identified. Among these are two missense variants, one alteration of a consensus splice donor sequence, and a variant that potentially disrupts translational initiation. CONCLUSION: BRCA1 and BRCA2 mutations appear to account for a lower proportion of breast cancer patients at increased risk of harboring such mutations in Northern India (6/204, 2.9%) than has been reported in other populations. However, given the limited extent of reported family history among these patients, the observed mutation frequency is not dissimilar from that reported in other cohorts of early onset breast cancer patients. Several of the identified mutations are unique and novel to Indian patients

Unusual squamous cell carcinoma of the scrotum arising from a well healed, innocuous scar of an infertility procedure: a case report

A novel case of squamous cell carcinoma of scrotum that developed in a well-healed, uncomplicated scar following an infertility procedure

Guided tooth eruption: Comparison of open and closed eruption techniques in labially impacted maxillary canines

Background: After third molars, the maxillary canines are the most commonly impacted permanent teeth and one-third of these are labial impactions. Impacted canines often require orthodontic guidance in the eruption. This study was conducted to assess the posttreatment results of surgically exposed and orthodontically aligned labially impacted maxillary canines comparing two different surgical techniques. Materials and Methods: The study was conducted in two phases, a surgical phase and an orthodontic phase. In surgical phase, events during surgical exposure and recovery of 31 patients with labially impacted maxillary canine were recorded. Patients were managed with open and closed eruption technique. The assessment included comparison of two techniques of surgical exposure, postoperative pain, mobility, vitality, periodontal health, level of impaction, and duration of orthodontic treatment. Results: The postoperative recovery was longer after open eruption than close eruption technique (P = 0.000). Postoperative pain experienced by patients was similar, but regression of pain was faster in closed eruption technique. The mean surgical time for open eruption technique was lesser when compared with closed eruption technique (P = 0.000). The total duration of orthodontic treatment was directly dependent upon the level of impaction, with deeper level of impaction having longer duration of orthodontic treatment. The mobility and vitality of guided canine was similar in both techniques. Conclusion: The closed eruption technique was a longer surgical procedure, but the postoperative pain regression was faster. The duration of orthodontic treatment was longer with deeper level of impaction. The closed eruption surgical techniques provide better periodontal tissues around the guided erupted teeth

Heparin: Induced thrombocytopenia: Incidence and laboratory approach to diagnosis in Indians

Background and objectives: One of the most common complications of heparin administration is heparin-induced thrombocytopenia (HIT) which can also lead to catastrophic thrombotic events. The problem of identifying the cause of thrombocytopenia, as due to heparin, in patients with multiple co-morbid conditions is very essential for management. Thus, the laboratory investigations for diagnosis of HIT play a pivotal role. The objective of the study was to arrive at the incidence of HIT in ethnic Indian population and provide a decision after analysis of tests used to diagnose HIT. Materials and Methods: 125 consecutive patients (Power of study being 80%) undergoing open heart surgery and receiving unfractionated heparin were taken as subjects. Blood samples were collected a day before the surgery and days 1, 3, 5 and 7 after surgery. The cases were categorized into probable and unlikely groups depending on the clinical presentation and degree fall of platelet count. Anti-heparin PF4-associated antibodies were detected using rapid-ID gel microtyping system and ELISA tests. HIT was also tested using functional assays:- heparin-induced platelet aggregation test (PAT) and the rapid luminographic assay of heparin-induced ATP release. Results: Of the 125 patients, 11 patients were clinically labeled as probable HIT and 29 patients were clinically labeled as unlikely HIT. There were seven confirmed cases of HIT cases that were positive for one functional and one immunological assay. Only one case of HITT was encountered. Accordingly, the incidence of HIT was found to be 5.6 % and that of HITT to be 0.8%. ELISA tests were positive in 21 cases (17%) which demonstrated the presence of anti-HPF4 antibodies in non-HIT cases as well. It was found that the rapid gel test had sensitivity comparable to functional assay with better specificity than ELISA. Interpretation and conclusions: Incidence of HIT in ethnic Indian population is 5.6%. Patients with a drop of >50% in platelet count should be perused as a likely candidate of HIT. These cases should be subjected to the ID-HPF4 antibody assay as this is a rapid test, can be done for individual cases, and has better specificity and similar sensitivity than ELSIA. Cases with clinically probable HIT and a positive ID-HPF4 assay can be taken as confirmed cases of HIT. However, cases clinically unlikely for HIT and a positive ID-HPF4 assay should be subjected to another test to establish the diagnosis of HIT

Effect of Robot-Assisted Radical Cystectomy With Intracorporeal Urinary Diversion vs Open Radical Cystectomy on 90-Day Morbidity and Mortality Among Patients With Bladder Cancer: A Randomized Clinical Trial

Importance: Robot-assisted radical cystectomy is being performed with increasing frequency, but it is unclear whether total intracorporeal surgery improves recovery compared with open radical cystectomy for bladder cancer. / Objectives: To compare recovery and morbidity after robot-assisted radical cystectomy with intracorporeal reconstruction vs open radical cystectomy. / Design, Setting, and Participants: Randomized clinical trial of patients with nonmetastatic bladder cancer recruited at 9 sites in the UK, from March 2017-March 2020. Follow-up was conducted at 90 days, 6 months, and 12 months, with final follow-up on September 23, 2021. / Interventions: Participants were randomized to receive robot-assisted radical cystectomy with intracorporeal reconstruction (n = 169) or open radical cystectomy (n = 169). Main Outcomes and / Measures: The primary outcome was the number of days alive and out of the hospital within 90 days of surgery. There were 20 secondary outcomes, including complications, quality of life, disability, stamina, activity levels, and survival. Analyses were adjusted for the type of diversion and center. / Results: Among 338 randomized participants, 317 underwent radical cystectomy (mean age, 69 years; 67 women [21%]; 107 [34%] received neoadjuvant chemotherapy; 282 [89%] underwent ileal conduit reconstruction); the primary outcome was analyzed in 305 (96%). The median number of days alive and out of the hospital within 90 days of surgery was 82 (IQR, 76-84) for patients undergoing robotic surgery vs 80 (IQR, 72-83) for open surgery (adjusted difference, 2.2 days [95% CI, 0.50-3.85]; P = .01). Thromboembolic complications (1.9% vs 8.3%; difference, -6.5% [95% CI, -11.4% to -1.4%]) and wound complications (5.6% vs 16.0%; difference, -11.7% [95% CI, -18.6% to -4.6%]) were less common with robotic surgery than open surgery. Participants undergoing open surgery reported worse quality of life vs robotic surgery at 5 weeks (difference in mean European Quality of Life 5-Dimension, 5-Level instrument scores, -0.07 [95% CI, -0.11 to -0.03]; P = .003) and greater disability at 5 weeks (difference in World Health Organization Disability Assessment Schedule 2.0 scores, 0.48 [95% CI, 0.15-0.73]; P = .003) and at 12 weeks (difference in WHODAS 2.0 scores, 0.38 [95% CI, 0.09-0.68]; P = .01); the differences were not significant after 12 weeks. There were no statistically significant differences in cancer recurrence (29/161 [18%] vs 25/156 [16%] after robotic and open surgery, respectively) and overall mortality (23/161 [14.3%] vs 23/156 [14.7%]), respectively) at median follow-up of 18.4 months (IQR, 12.8-21.1). / Conclusions and Relevance: Among patients with nonmetastatic bladder cancer undergoing radical cystectomy, treatment with robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy resulted in a statistically significant increase in days alive and out of the hospital over 90 days. However, the clinical importance of these findings remains uncertain. / Trial Registration: ISRCTN Identifier: ISRCTN13680280; ClinicalTrials.gov Identifier: NCT03049410