Introduction: External rotation of femoral component is controversial in Total knee arthroplasty (TKA). The aim of our study is to assess the precision of femoral component external rotation in Robotic Assisted All Burr TKA. Materials and methods: This is a prospective study of 30 cases who underwent All Burr Robotic Assisted TKA at our institute, RNH hospital. Inclusion criteria were primary and secondary osteoarthritis of the knee and exclusion criteria were revision and partial knee replacement. On Navio robotic system femoral external rotation was planned as per medio-lateral flexion gap balancing and executed with burr. Post-operative CT scan was done in all patients to assess intra-operative planned femoral external rotation. Results: Out of 30 cases, 20 were female and 10 were male. Mean age was 66.06±7.43 years. On Navio the planned external rotation of femoral component was 2.86±1.16. Average of femoral component external rotation on postoperative CT scan was 3.11±1.16. The mean deviation of achieved femoral component external rotation from planned external rotation was -0.24 to ±0.28. Only 37% patients required 3° external rotation. Correlation between planned and achieved femoral component external rotation was significant, positive and very strong as indicated by r=0.97 and p=0.0001. Conclusion: All Burr Robotic Assisted TKA provides near accurate femoral component external rotation as planned on Navio with deviation of less than 0.3° between planned and achieved external rotation.

Introduction: Traditional galactogogue recipes are still being used, though not widely, and scientific studies on their use are scanty. This research aimed to study commonly used traditional galactogogue-recipes using primary sources, to bring about nutritional enhancement in most popular recipes and compare the standard and nutrified galactogogue-recipes for nutrients, phytochemicals and sensory qualities. Methods: A cross-sectional survey was carried out among 120 mothers (older than 20 years) residing in Indian states of Rajasthan and Uttar-Pradesh in their 0-1 year of lactation period who consented to be a part of the study. Background-information and use of galactogogues was collected with the help of self-designed, pre-tested questionnaires. Nutritive-value (moisture, ash, protein, fat, dietary-fibre, carbohydrate, iron, and calcium) of two of the most popular galactogogues ajwain-laddu and harira were calculated to find out the nutrient(s) lacking in it. Ajwain-laddu was nutrified using whole milk-powder, drumstick leaves powder and additional amount of clarified-butter. Harira was nutrified using poppy-seeds, niger-seeds and carrots. Results: The commonly used galactogogues were ajwain-laddu, harira, Gond-laddu, and Sonth-laddu. There was a significant difference between nutrient content of standard and nutrified-recipes (p<0.05) whereas no statistical difference was observed for hedonic rating-scores (p>0.05). Conclusion: Mothers were consuming traditional galactogogues foods in order to increase milk production and strongly believed that regular consumption of galactogogues has enhanced their milk production. To optimize the nutritional value of galactogogues, it is advisable to integrate ingredients abundant in phytochemicals and micronutrients. This can be accomplished while preserving the authentic taste and presentation of these galactogogue-recipes.

Bilateral transverse thoracosternotomy, or “clamshell” thoracotomy, can be complicated by dehiscence. A 65-year-old male underwent lung transplantation via clamshell thoracotomy, with subsequent sternal dehiscence on postoperative day 11. Upon repair, the previous sternal wires had pulled through, so a Sternal Talon connected to a Recon Talon was utilized to re-approximate the inferior sternum. On follow-up at 3 months, the patient recovered well. Use of the Sternal Talon provides an effective technique for repairing transverse sternal dehiscence.

OBJECTIVE: To extract and isolate berberine from Berberis aristata (Berberidaceae). Isolated berberine was characterised using spectroscopy and its antioxidant and antiarthritic activity was analyzed. METHODS: The berberine was isolated from B. aristata using microwave-assisted extraction (MAE) and characterised by a spectroscopic technique. The isolated berberine was evaluated for its antioxidant activity in DPPH, nitric oxide, and superoxide scavenging assays, while antiarthritic activity was evaluated in the complete freund's adjuvant (CFA)-induced arthritis rat model. RESULTS: The antioxidant activity of berberine revealed potent antioxidant activity in DPPH, nitric oxide, and superoxide scavenging assays. The in vivo antiarthritic activity of berberine in the CFA-induced arthritis rat model showed a significant reduction in paw diameter, arthritic score, and an increase in body weight. Furthermore, a concentration-dependent ameliorating action of berberine on haematological parameters was noticed. Proinflammatory biomarkers, including IL-6, IL-10, and TGF-b in serum were reported, and histopathology examination revealed that berberine decreased pannus formation, synovial hyperplasia, and bone erosion. Radiographic investigation showed soft tissue inflammation, bone resorption and erosion, joint gap reduction, and substantial connective tissue expansion after treatment with berberine. CONCLUSION The ameliorating action on haematological parameters and proinflammatory biomarkers of berberine makes them a suitable remedy for the treatment of arthritis.

Background/Aims: The mechanism via which supra-esophageal symptoms are generated is unclear. We assessed upper esophageal sphincter (UES) function in novel fashion using functional lumen imaging probe (FLIP) topography. We hypothesize that symptoms related to aspiration of esophageal contents may be associated with a more distensible UES. Methods: FLIP and reflux symptom index score data from patients undergoing diagnostic evaluation for an esophageal complaint over a 10-month period were analyzed retrospectively. UES distensibility on FLIP was studied at 40-70 mL volumes with in-depth analysis at 50 and 60 mL. Symptoms were compared between patients with low, middle, and high UES-distensibility index (UES-DI). Receiveroperating characteristic analysis was performed to determine associations between the UES-DI and individual reflux symptom index symptom item scores. Results: One hundred and eleven subjects were included. Overall, the associations between UES-DI and symptoms that could be related to supra-esophageal aspiration were strongest at the 50 mL FLIP volume. Choking item score was highest in the high UES-DI group (2.8) vs 1.4 (P < 0.001) in the middle UES-DI and 1.1 (P = 0.004) in the low UES-DI groups. Similarly, the cough item score was highest in the high UES-DI group (2.7) vs 1.5 (P = 0.009) and 0.9 (P = 0.002) groups. Conclusion A higher UES-DI measures defective barrier function which could may be the main pathophysiology that generates supra-esophageal symptoms.

Background: The low detection rate of tuberculosis (TB) cases in Malaysia remains a challenge in the effort to end TB by 2030. The collaboration between private and public health care facilities is essential in addressing this issue. As of now, no private-public health care collaborative program in pulmonary tuberculosis (PTB) screening exists in Malaysia. Aim: To determine the feasibility of a collaborative program between private general practitioners (GPs) and the public primary health clinics in PTB screening and to assess the yield of smearpositive PTB from this program. Methods: A prospective cohort study using convenient sampling was conducted involving GPs and public health clinics in the North-East District, Penang, from March 2018 to May 2019. In this study, GPs could direct all suspected PTB patients to perform a sputum acid fast bacilli (AFB) direct smear in any of the dedicated public primary health clinics. The satisfaction level of both the GPs and their patients were assessed using a self-administered client satisfaction questionnaire. IBM SPSS Statistical Software was used to analyze the data. Results: Out of a total of 31 patients who underwent the sputum investigation for PTB, one (3.2%) was diagnosed to have smear-positive PTB. Most of the patients (>90%) and GPs (66.7%) agreed to continue with this program in the future. Furthermore, most of the patients (>90%) were satisfied with the program structure. Conclusion: It is potentially feasible to involve GPs in combating TB. However, a more structured program addressing the identified issues is needed to make the collaborative program a success.
Food Insecurity ; Malaysia ; Adult ; Nutrition Survey

Introduction: An increased tibial tuberosity-trochlear groove (TTTG) distance is used for deciding a treatment plan in patello-femoral instability (PFI). The centre of the patellar tendon and the chondral trochlear groove can be directly visualised on MRI, and measured, giving the patellar tendontrochlear groove (PTTG) distance. A study was designed to compare the inter-rater and the test-retest reliabilities of PTTG and TTTG measurements in MRI of patients without PFI and in a group with PFI. Materials and Methods:This cross-sectional reliability study was done on archival MRI films of 50 patients without patellar instability and 20 patients with patellar instability. TTTG and PTTG distances were independently measured by two orthopaedic surgeons and two radiologists. A hybrid PTTG measurement with bony landmarks on the femoral side and the patellar tendon landmark on the tibial side, was used to estimate the influence of the differences in the femoral and tibial landmarks on the difference in reliabilities. The intra-class correlation coefficient (ICC) was calculated for all four raters, as well as separately for each rater. Results: The PTTG distance had a higher inter-rater reliability (ICC=0.86, 95% CI=0.79-0.92) compared to the TTTG distance (ICC=0.70, 95% CI=0.59-0.80) in patients without PFI. Similar trends were seen in patients with PFI (0.83 vs 0.66). The inter-rater reliability for the hybrid PTTG distance was found to lie in between the TTTG and PTTG. Conclusions:The MRI-based PTTG distance had better inter-rater reliability compared with the MRI-based TTTG distance.

Abdominal pain is a common but benign symptom after colonoscopy. We report a case of acute pancreatitis that occurred just after an elective screening colonoscopy; this is a rare event with very few reported cases. A healthy, asymptomatic male underwent screening colonoscopy at our center and developed abdominal pain and emesis after the procedure. An abdominal X-ray ruled out perforation but laboratory tests revealed elevated levels of amylase and lipase. The patient had no etiological risk factors for pancreatitis. The presumed mechanism of pancreatitis in this case is mechanical and pressure trauma from excessive insufflation, external abdominal pressure, and repeated withdrawal of the colonoscope due to tight angulation of the splenic flexure, a structure that is in close proximity to the pancreatic tail. Acute pancreatitis should be considered in the differential diagnosis of patients who present with abdominal pain after colonoscopy once more common etiologies have been excluded.

The role of the microbiome in health and human disease has emerged at the forefront of medicine in the 21st century. Over the last 2 decades evidence has emerged to suggest that inflammation-derived oxidative damage and cytokine induced toxicity may play a significant role in the neuronal damage associated with Parkinson's disease (PD). Presence of pro-inflammatory cytokines and T cell infiltration has been observed in the brain parenchyma of patients with PD. Furthermore, evidence for inflammatory changes has been reported in the enteric nervous system, the vagus nerve branches and glial cells. The presence of α-synuclein deposits in the post-mortem brain biopsy in patients with PD has further substantiated the role of inflammation in PD. It has been suggested that the α-synuclein misfolding might begin in the gut and spread “prion like” via the vagus nerve into lower brainstem and ultimately to the midbrain; this is known as the Braak hypothesis. It is noteworthy that the presence of gastrointestinal symptoms (constipation, dysphagia, and hypersalivation), altered gut microbiota and leaky gut have been observed in PD patients several years prior to the clinical onset of the disease. These clinical observations have been supported by in vitro studies in mice as well, demonstrating the role of genetic (α-synuclein overexpression) and environmental (gut dysbiosis) factors in the pathogenesis of PD. The restoration of the gut microbiome in patients with PD may alter the clinical progression of PD and this alteration can be accomplished by carefully designed studies using customized probiotics and fecal microbiota transplantation.
Animals ; Anti-Bacterial Agents ; Biopsy ; Brain ; Brain Stem ; Cytokines ; Deglutition Disorders ; Dysbiosis ; Enteric Nervous System ; Fecal Microbiota Transplantation ; Gastrointestinal Microbiome ; Humans ; In Vitro Techniques ; Inflammation ; Mesencephalon ; Mice ; Microbiota ; Neuroglia ; Neurons ; Parkinson Disease ; Probiotics ; Vagus Nerve

BACKGROUND/AIMS: The data on the risk of tuberculosis (TB) reactivation with infliximab (IFX) in patients with inflammatory bowel disease (IBD) from TB endemic countries, like India, is limited. The risk of TB reactivation on IFX and its predictors in patients with IBD was assessed. METHODS: This retrospective review included consecutive patients with IBD who received IFX, and were on follow-up from January 2005 to November 2017. The data was recorded on age/disease duration, indications for IFX, screening for latent tuberculosis (LTB) before IFX, response to IFX, incidence and duration when TB developed after IFX, and type of TB (pulmonary [PTB]/extra-pulmonary [EPTB]/disseminated). RESULTS: Of 69 patients (22 ulcerative colitis/47 Crohn’s disease; mean age, 35.6±14.5 years; 50.7% males; median follow-up duration after IFX, 19 months [interquartile range, 5.5–48.7 months]), primary non-response at 8 weeks and secondary loss of response at 26 and 52 weeks were seen in 14.5%, 6% and 15% patients respectively. Prior to IFX, all patients were screened for LTB, 8 (11.6%) developed active TB (disseminated, 62.5%; EPTB, 25%; PTB, 12.5%) after a median of 19 weeks (interquartile range, 14.0–84.5 weeks) of IFX. Of these 8 patients’ none had LTB, even when 7 of 8 were additionally screened with contrast-enhanced chest tomography. Though not statistically significant, more patients with Crohn’s disease than ulcerative colitis (14.9% vs. 4.5%, P=0.21), and those with past history of TB (25% vs. 9.8%, P=0.21), developed TB. Age, gender, disease duration, or extraintestinal manifestations could not predict TB reactivation. CONCLUSIONS: There is an extremely high rate of TB with IFX in Indian patients with IBD. Current screening techniques are ineffective and it is difficult to predict TB after IFX.
Colitis, Ulcerative ; Crohn Disease ; Follow-Up Studies ; Humans ; Incidence ; India* ; Inflammatory Bowel Diseases* ; Infliximab* ; Interferon-gamma Release Tests ; Latent Tuberculosis ; Male ; Mass Screening* ; Retrospective Studies ; Thorax ; Tuberculosis* ; Ulcer