Functional and radiological outcome of wedgeless ‘V’ osteotomy for genu valgum in adolescents: a prospective cohort study

Background: Genu valgum, commonly called "knock-knee, is a coronal plane angular deformity of knee, which is a common disorder affecting children and adolescents. Distal femoral wedgeless V osteotomy is one of the various methods of treating genu valgum.Methods: A prospective cohort study was conducted between July 2017 to March 2020 in Govt Medical College, Jammu on 28 patients of genu valgum with femoral deformity. A wegdeless V osteotomy was done at the supracondylar level and fixed with K wires. The results were compaired on the basis of radiological parameters such as TFA and MAD. IMD was also compared. The functional outcome was evaluated using Bostman knee score at 6 months of follow-up. 1 patient was lost in follow up and was not included in the study.Results: 27 patients were included in the study with a mean age of 17.5 years (range 15-21 years). The radiological parameters such as TFA showed improvement from a mean of 20.71 to 5.87 postoperatively. IMD decreased from a mean of 13.77 cm to 3.69 cm and MAD from 18.76 mm to 3.03 mm. The functional assessment was made using Bostman score with a mean of 27.1 at final follow up.Conclusions: Supracondylar wedgeless V-osteotomy is an excellent technique for correction of the genu valgum deformity in the adolescent. The learning curve, surgical exposure, and surgical time being minimal. Sparse complications have been reported with this technique as compared to the other type of osteotomies

Functional outcome of long proximal femoral nail versus short proximal femoral nail in peritrochanteric fractures

Background: Proximal femoral nail (PFN) is an intramedullary implant which has been commonly used in the fixation of intertrochanteric fractures. However, controversy comes about the effect of nail length on fracture union and other complications. A comparative evaluation of surgical treatment and functional outcome of patients with peritrochanteric fractures treated with short versus long PFN.Methods:  Total of 100 patients have been included in study out of which 57 belonged to group 1 and were operated with short PFN and rest 43 were group 2 operated with long PFN. Patients were followed up for 6 months and were compared on various parameters.Results: There is no significant difference noted in the two group. However, the surgical duration and blood loss for short PFN was significantly less as compared to long PFN.Conclusions: Short PFN is better implant for peritrochantric fractures both stable and unstable with quicker surgical time and lesser blood loss

Causal ambiguity: deciphering the etiology of secondary thrombotic microangiopathy with systemic lupus erythematosus and vivax malaria

Hemolytic uremic syndrome (HUS) falls under the spectrum of thrombotic microangiopathy (TMA) characterized by microangiopathic hemolytic anemia, thrombocytopenia, and thrombi in small vessels leading to end-organ damage. It's classified into typical HUS (caused by Shiga toxin-producing E. coli), atypical HUS (due to uncontrolled complement activation), and secondary HUS (sHUS) linked with coexisting conditions. We present a compelling case of a 21-year-old female with fever, jaundice, anemia, thrombocytopenia, and oliguric acute kidney injury (AKI), ultimately diagnosed with Plasmodium vivax malaria. Despite adequate antimalarial therapy, the patient's clinical trajectory remained intricate, characterized by sustained hematological abnormalities and renal dysfunction. A comprehensive assessment revealed Coombs-negative hemolytic anemia. Subsequently, a renal biopsy confirmed TMA. Considering the rarity of vivax malaria causing TMA, an autoimmune workup was conducted, suggesting systemic lupus erythematosus (SLE). Systemic autoimmune disease-associated HUS (SAID-HUS) is a rare entity that exhibits diverse clinical presentations, with SLE being best-described etiology in literature. SLE-associated HUS was considered and was managed with steroids and hydroxychloroquine resulting in significant renal and hematological improvement. This report underscores significance of assessing autoimmune factors in case of secondary TMA, while also shedding light on evolving understanding of vivax malaria's potential relationship with TMA

Seizure and Hepatosplenomegaly—Rare Manifestation of Parvovirus B-19: A Case Report and Review of the Literature

Parvovirus B19 is the etiologic agent of erythema infectiosum (fifth disease), a fever-rash illness occurring in childhood. We present a 10 month old child with high grade fever for 10 days, generalized tonic-clonic seizure, bilateral cervical lymphadenopathy, generalized maculopapular rash, hematemesis and malena. Bone marrow aspiration and liver biopsy were done. EBV serology and parvovirus PCR were also performed. Bone marrow aspiration and biopsy showed giant pro-erythroblast consistent with parvovirus infection. PCR showed amplification of parvovirus genomic sequences. Present case highlights an atypical presentation of Parvovirus B19 infection as fever, rash and hepatosplenomegaly

First metatarsal bone reconstruction using Masquelet’s technique after bone loss in open III B injury

Background: Masquelet technique involves two stages for reconstruction of bony defects. During stage one decontamination and debridement is performed. The bone defect is filled by a spacer made of bone cement. After a gap of around 6 weeks, a bio-membrane is established around the cement spacer. During stage two, the cement spacer is removed and cancellous autologous bone graft is used to fill the space that was previously occupied by the cement spacer. However, there is a huge scarcity of literature on reconstruction of bone defects in foot metatarsals, especially open injuries that require soft tissue coverage also. Methods: This prospective study involved 25 patients with a minimum follow-up of 12 months. Masquelet’s technique was used to reconstruct large bony defects in metatarsals of foot in a staged manner. The primary outcome variable was union and consolidation of the bone. The secondary outcome variables included complications and functional outcome using Maryland foot score.  Results: One of the patients needed a below knee amputation for extensive bone and soft tissue infection. Pin site infection was the commonest indication observed and deep infection was observed on table at the time of second stage in two patients. Both the patients needed a re-do of stage one and a new cement spacer was placed which was removed at six weeks. Hallux varus deformity was observed in two patients at the final follow-up. Excluding the patient that needed amputation, all the patients had consolidation and union at the final follow-up and the mean Maryland foot score was 79.45±8.8. Good to excellent functional outcome was observed among 91.66% patients.     Conclusions: Masquelet’s induced membrane technique is a potentially fruitful method to deal with bone defects created by open fractures of metatarsals of feet. However, due to limited sample size and lack of control group, we recommend large scale randomized control trials be conducted on the subject.

Pharmacogenomics of GLP-1 receptor agonists: a genome-wide analysis of observational data and large randomised controlled trials

Background: In the treatment of type 2 diabetes, GLP-1 receptor agonists lower blood glucose concentrations, body weight, and have cardiovascular benefits. The efficacy and side effects of GLP-1 receptor agonists vary between people. Human pharmacogenomic studies of this inter-individual variation can provide both biological insight into drug action and provide biomarkers to inform clinical decision making. We therefore aimed to identify genetic variants associated with glycaemic response to GLP-1 receptor agonist treatment. Methods: In this genome-wide analysis we included adults (aged ≥18 years) with type 2 diabetes treated with GLP-1 receptor agonists with baseline HbA1c of 7% or more (53 mmol/mol) from four prospective observational cohorts (DIRECT, PRIBA, PROMASTER, and GoDARTS) and two randomised clinical trials (HARMONY phase 3 and AWARD). The primary endpoint was HbA1c reduction at 6 months after starting GLP-1 receptor agonists. We evaluated variants in GLP1R, then did a genome-wide association study and gene-based burden tests. Findings: 4571 adults were included in our analysis, of these, 3339 (73%) were White European, 449 (10%) Hispanic, 312 (7%) American Indian or Alaskan Native, and 471 (10%) were other, and around 2140 (47%) of the participants were women. Variation in HbA1c reduction with GLP-1 receptor agonists treatment was associated with rs6923761G→A (Gly168Ser) in the GLP1R (0·08% [95% CI 0·04–0·12] or 0·9 mmol/mol lower reduction in HbA1c per serine, p=6·0 × 10−5) and low frequency variants in ARRB1 (optimal sequence kernel association test p=6·7 × 10−8), largely driven by rs140226575G→A (Thr370Met; 0·25% [SE 0·06] or 2·7 mmol/mol [SE 0·7] greater HbA1c reduction per methionine, p=5·2 × 10−6). A similar effect size for the ARRB1 Thr370Met was seen in Hispanic and American Indian or Alaska Native populations who have a higher frequency of this variant (6–11%) than in White European populations. Combining these two genes identified 4% of the population who had a 30% greater reduction in HbA1c than the 9% of the population with the worse response. Interpretation: This genome-wide pharmacogenomic study of GLP-1 receptor agonists provides novel biological and clinical insights. Clinically, when genotype is routinely available at the point of prescribing, individuals with ARRB1 variants might benefit from earlier initiation of GLP-1 receptor agonists. Funding: Innovative Medicines Initiative and the Wellcome Trus