Publications by authors named "Keshav Kumar Gupta"

24 Publications

  • Page 1 of 1

The Effect of COVID on Nasal Fracture Management in ENT Emergency Clinics.

Craniomaxillofac Trauma Reconstr 2022 Jun 5;15(2):98-103. Epub 2021 May 5.

Queen Elizabeth Hospital, Birmingham, UK.

Study Design: Retrospective cohort study.

Objective: Management of nasal fractures is usually in ENT emergency clinics, with our center aiming to assess patients within 10-days. During 2020, there have been numerous lockdowns and social distancing measures implemented in the UK as a result of the coronavirus pandemic (COVID). This study aimed to assess the effect of COVID on nasal fracture management in ENT emergency clinics in terms of number of patients seen, time to follow up and their management strategies.

Methods: All patients with suspected or confirmed nasal bone fractures presenting to the emergency department (ED) between January 1, 2019 and December 31, 2020 at our major trauma center were analyzed in 2 groups depending on the year they were seen (2019 vs. 2020).

Results: There was a total of 104 patients analyzed, with 51.4% decrease in the number of patients seen in 2020 versus 2019. The mean days to follow up in 2019 was 8.09 days and 7.65 days in 2020 ( = .37). There was no statistically significant difference in the number of patients seen within the 10-day target between years (2019 = 65.7% vs. 2020 = 76.5%, = .35). The majority of patients were managed with manipulation under anesthesia (MUA) in 2019 (n = 32, 45.7%) vs. discharge from clinic in 2020 (n = 21, 61.8%).

Conclusions: Our study shows a drastic reduction in the number of patients seen in ENT emergency clinic from 2019 to 2020. This is in-keeping with other studies that have shown a reduction in ED attendances, trauma admissions and admissions across other specialties all around the world.
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http://dx.doi.org/10.1177/19433875211015036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9133521PMC
June 2022

The efficacy and safety of intrathecal fluorescein in endoscopic cerebrospinal fluid leak repair -a systematic review.

Auris Nasus Larynx 2022 Dec 4;49(6):912-920. Epub 2022 Apr 4.

Department of Otorhinolaryngology, Queen Elizabeth Hospital, Birmingham, B15 2TH, United Kingdom.

Background: Effective management of cerebrospinal fluid (CSF) leaks can reduce significant associated morbidity. Intrathecal fluorescein (IF) may be a valuable intra-operative adjunct to localise leak sites. Recent reports have demonstrated low doses of IF to be safe, however, no internationally accepted dose of IF has been agreed.

Objective: To assess the efficacy and safety of IF used in the endoscopic management of anterior skull base CSF fistulae.

Methods: A systematic review and descriptive analysis were performed of all published data in accordance to PRISMA guidelines.

Results: There were 18 included articles giving a total of 335 procedures where IF was used. Doses of IF ranged from 10mg - 150mg. IF positively identified the site of CSF fistula in 88.7% of cases (n = 297). There was a total of 25 reported peri-operative complications in all included studies (7.5%) with 5.1% (n = 17) potentially related to IF use. Of these, the complication rate was 3.9% at low IF doses (<50mg) and 80.0% at higher doses (≥50mg).

Conclusion: Our review demonstrates that IF is effective at localising CSF fistulae with most significant complications being related to doses ≥50mg. We therefore propose that there is a potential for the licensing of IF in this field. Doses <50mg have consistently been shown to be safe while still maintaining effective localisation rates. Based on the most common doses used in this group, we recommend utilisation of a dosing below 50mg, with the most frequent range being between 10-30mg.
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http://dx.doi.org/10.1016/j.anl.2022.03.014DOI Listing
December 2022

Medical management of rhinitis in pregnancy.

Auris Nasus Larynx 2022 Dec 4;49(6):905-911. Epub 2022 Feb 4.

University Hospitals Birmingham NHS Trust. Heartlands Hospital. Bordesley Green East. Birmingham. B9 5SS, United Kingdom.

Medical treatment options for patients with rhinitis during pregnancy need careful considerations. It is important to distinguish between the causes of rhinitis, as this can influence treatment. Conservative options are important for patients with pregnancy-induced rhinitis (PIR) and pre-existing allergic or non-allergic rhinitis. Education and knowledge that PIR symptoms will resolve after pregnancy can offer some relief. Other strategies such as exercise, positioning, saline nasal douching/lavage, and nasal valve dilators are safe in pregnancy and can have a benefit in these patients with rhinitis of any aetiology. The main medical therapies usually used in rhinitis cannot always be directly translated to pregnant patients due to potential teratogenic effects. Topical corticosteroids have generally shown to be safe with budesonide having the strongest recommendations. Oral corticosteroids are mostly used in moderate-severe disease and should be avoided in the first trimester. Oral decongestants have associations with cardiac, ear, gut and limb abnormalities and are not recommended in the first trimester. Loratadine and cetirizine have been the most well-studied second-generation antihistamines and are generally considered safe. There has been no reported increased risk of teratogenicity with anticholinergics or cromones, with the latter being one of the first line options in pregnant women with allergic rhinitis. The role of allergen immunotherapy needs further research, but current guidance states it can be continued if already initiated prior to pregnancy. The management of rhinitis in pregnancy can therefore be complex. This review aims to evaluate the current medical management options for rhinitis in pregnancy.
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http://dx.doi.org/10.1016/j.anl.2022.01.014DOI Listing
December 2022

The evolution of sinus surgery in England in the last decade - An observational study.

World J Otorhinolaryngol Head Neck Surg 2021 Jul 19;7(3):240-246. Epub 2020 Oct 19.

Department of Otolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, United Kingdom.

Background And Objective: Sinus surgery has seen significant changes over the years with advancements in instruments, endoscopes and imaging. This study aimed to use Hospital Episode Statistics (HES) data to review the total number of sinus related procedures performed in both adults and children across England and identify whether there were any trends across the study period. We predicted an increase in endoscopic sinus procedures with a decline in open approaches to the paranasal sinuses.

Methods: Data from HES was extracted for the years 2010-2019. The operative (OPCS-4) codes relevant to all sinus procedures between E12.1 and E17.9 were analysed. After examination of overall sinus related procedures, further subgroup analysis was performed with regards to open or endoscopic techniques.

Results: The total number of sinus procedures performed between 2010 and 2019 was 89,495. There was an increase in endoscopic surgeries by 21.1% and a decrease of open surgeries 35.3% during this time. There was an overall increase in maxillary, frontal and sphenoid sinus procedures, with a decrease in ethmoid sinus and lateral rhinotomy operations. There was an increase in the proportion of endoscopic cases overall by 5.7% and for all sinuses individually.

Conclusion: Overall, we see an increase in sinus surgery over the last 9 years from 2010 to 2019. These findings are in keeping with our initial hypotheses. Although our data set is limited by coding, and lack of patient factors, it represents most, if not all, of the data in England over a large study period. It is therefore useful to add to previous studies when demonstrating the increasing popularity of endoscopic sinus surgery over open procedures.
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http://dx.doi.org/10.1016/j.wjorl.2020.10.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8356113PMC
July 2021

A Basic Intervention to Improve Compliance With Thromboprophylaxis in Patients With Neck of Femur Fracture.

Ochsner J 2021 ;21(2):173-176

Department of Orthopedics, Sandwell and West Birmingham NHS Trust, Sandwell General Hospital, Birmingham, UK.

Venous thromboembolism (VTE) is a significant complication following orthopedic intervention for neck of femur fracture. Our aim was to evaluate compliance with The National Institute for Health and Care Excellence guidance surrounding VTE prophylaxis before and after a brief intervention in an orthopedic department at a district general hospital. A 2-cycle quality improvement project was conducted. The primary outcome measure was whether adequate thromboprophylaxis was appropriately prescribed. For the intervention between the 2 cycles, posters were placed in key prescribing areas of all orthopedic wards. In cycle 1, 63 (76.8%) patients were correctly prescribed enoxaparin, and 14 (17.1%) were prescribed other anticoagulants, leaving 5 patients (6.1%) who did not receive thromboprophylaxis for no apparent reason. In cycle 2, 56 (87.5%) patients were correctly prescribed enoxaparin, and the remaining patients were covered with alternative therapies. Small but basic interventions can lead to improvements in VTE prophylaxis prescribing. Future focus should be on implementing similar interventions across hospitals.
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http://dx.doi.org/10.31486/toj.20.0093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8238106PMC
January 2021

The Effectiveness and Safety of Intrathecal Fluorescein in the Management of Cerebrospinal Fluid Leaks.

Am J Rhinol Allergy 2021 Nov 1;35(6):879-884. Epub 2021 Jun 1.

Department of Otorhinolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.

Background: Cerebrospinal fluid (CSF) leaks can be associated with significant morbidity such as meningitis. Surgical management has proven effective, with endoscopic approaches having become the gold standard due to success rates >90%. Inability to localise the leak site prior to surgery is associated with surgical failure. The use of intrathecal fluorescein (IF) to localise CSF fistulae sites was first demonstrated in 1960. Despite this, its use in this context is unlicensed.

Objective: Evaluate the safety and efficacy of IF use in the management of CSF leak repairs in our centre.

Methods: All patients who underwent endoscopic repair of CSF fistula by a single surgeon where IF was used between January 2010 - September 2019 at a single-centre (tertiary skull base referral unit in the United Kingdom) were retrospectively analysed. Primary outcome measures were localisation of CSF fistula with IF (efficacy) and peri-operative complications likely to be attributable to IF (safety).

Results: There were 55 patients included (60 procedures) with a positive localisation rate of 90.0% with IF. The overall peri-operative complication rate was 8.3% (n = 5). It is likely that none were related to IF use. However, three complications may be linked giving a complication rate potentially related to IF of 5.0%. There were no peri-operative mortalities.

Conclusion: Many studies have demonstrated IF to be safe at low doses (<50mg) with a high sensitivity, specificity and positive predicative value. Our results demonstrate that the use of IF in our centre is safe and effective at identifying CSF fistulae. While we have reported some complications in our cohort, these were unlikely to be directly attributable IF use. We have described no serious complications such as seizures, limb weakness or death. We believe this study adds to the growing body of evidence that IF use in the management CSF fistula repairs is safe and effective.
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http://dx.doi.org/10.1177/19458924211020564DOI Listing
November 2021

Endoscopic transsphenoidal surgery reconstruction using the fibrin sealant patch Tachosil.

Br J Neurosurg 2021 Mar 26:1-10. Epub 2021 Mar 26.

Department of Otolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.

Introduction: The incidence of CSF leak following endoscopic transsphenoidal surgery remains the most important measure in the success of any repair. The nasoseptal flap (NSF) has played a pivotal role in reconstructing defects. However, morbidity associated with the NSF includes bleeding, septal injury, altered smell and crusting. Tachosil is an absorbable fibrin sealant patch that promotes haemostasis and wound healing. The purpose of this study was to evaluate the effectiveness of Tachosil to repair intraoperative defects during an endoscopic transsphenoidal approach.

Materials And Methods: All patients who underwent an endoscopic transsphenoidal approach with the use of Tachosil at the Queen Elizabeth Hospital Birmingham, between January 2013 and June 2020 were retrospectively analysed. Tachosil was used as an overlay patch over of the bony defect, in a multi-layered repair depending on the defect and grade of CSF leak. The primary outcome measure was post-operative CSF leak.

Results: A total of 52 primary procedures where Tachosil was used as the overlay were analysed. There were 23 (44.2%) intraoperative CSF leaks. The overall post-operative CSF leak rate was 7.8% ( = 4), with all cases having had a Tachosil overlay reconstruction with no NSF. A formal NSF was harvested in only five cases alongside the Tachosil patch, where a grade 2 or more leak was identified at the time of the primary procedure, none of which developed a post-operative leak. No patient had any post-operative adverse outcomes that were attributed to Tachosil.

Conclusions: We believe this to be the largest case series evaluating the endoscopic use of Tachosil in skull base reconstruction. Our data show that in endoscopic transsphenoidal approach, Tachosil may be used safely in a multi-layered approach as an effective alternative to the NSF in low flow CSF leak cases, or alongside a NSF in higher flow leaks.
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http://dx.doi.org/10.1080/02688697.2021.1905771DOI Listing
March 2021

Personal protective equipment guidance during a global pandemic: A statistical analysis of National perceived confidence, knowledge and educational deficits amongst UK-based doctors.

Int J Clin Pract 2021 May 27;75(5):e14029. Epub 2021 Jan 27.

Department of Otolaryngology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK.

Introduction: On the 11th of March 2020, the World Health Organisation (WHO) declared a global pandemic following the upsurge of the novel coronavirus disease 2019 (COVID-19). Unprecedented global demand for personal protective equipment (PPE) resulted in restricted availability, as well as evolving guidance on use, the latter of which was complicated by conflicting guidance provided by numerous healthcare bodies.

Aim: To assess perceived confidence and knowledge of PPE guidance as published by Public Health England (PHE) amongst doctors of varying specialties and grades.

Method: A nationwide 11-point survey comprising of multiple-choice questions (MCQs) and a 5-point Likert scale assessing perceived confidence was disseminated to UK-based doctors using multiple platforms. Statistical analysis using one-way analysis of variance (ANOVA), Tukey's honest significant difference (Tukey HSD) and Pearson's chi-squared test was undertaken to assess for statistical significance.

Results: Data collated from 697 respondents revealed that average perceived confidence was low across all specialties and grades. Notably, 59% (n = 411) felt they had received insufficient education regarding up-to-date guidance, with 81% (n = 565) advocating further training. Anaesthetics and ophthalmology were highest and lowest scoring specialties in knowledge-based MCQs, achieving scores of 59% and 31%, respectively. Statistical analysis revealed significant differences between specialty, but not grade.

Conclusion: Ensuring uniformity in published guidance, coupled with education may aid knowledge and subsequent confidence regarding the appropriate use of PPE. The absence of a unified consensus and sustained training not only poses significant ramifications for patient and healthcare professional (HCP) safety, but also risks further depletion of already sparse resources. Because of the novelty of COVID-19, appropriate PPE is continually evolving leaving an absence in formal training and education. This paper reveals insight into confidence and knowledge of PPE amongst doctors of various specialities/grades during a global pandemic, highlighting key deficits in education and training.
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http://dx.doi.org/10.1111/ijcp.14029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7994994PMC
May 2021

Writing clinic letters in head and neck outpatient services-Are we doing what patients want?

Int J Clin Pract 2021 Apr 14;75(4):e13907. Epub 2020 Dec 14.

Department of Surgery, The Royal Wolverhampton NHS Trust, New Cross Hospital, Wolverhampton, UK.

Introduction: The Academy of Medical Royal Colleges have recently recommended all outpatient letters to be written directly to patients. We aimed to evaluate clinician and patient preferences for their outpatient letters from a head and neck department at a single-centre secondary care hospital.

Methods: A multiple-choice questionnaire was designed and circulated to patients over a 2-week period. The primary outcome measure was the patient preference for the writing style. In order to evaluate existing writing styles, clinic letters were retrospectively sampled from all consultant and registrar grade otolaryngology (ENT) and oral maxillofacial (OMFS) surgeons in the department. These were analysed for readability via Flesch Reading Ease Score and audience.

Results: Of all 80 included patient responses, 42 expressed a preference for letters to be written directly to the patient (52.5%). Only 5.0% (n = 4) of respondents exhibited a preference for letters to be written to their GP, with 42.5% (n = 34) of patients having no preference. All 54 surgeon letters (100%) were addressed to GPs. The average FRE score was 58.5, representing a reading level of "high school education."

Discussion: When considered in the wider body of similar studies, there is convincing evidence that patients would prefer letters to be written to them rather than GPs. The authors believe that there should be a push towards patient-directed letters becoming the norm. This will improve patients' understanding of their own health and treatment decisions, allowing them to be more involved in their care and increase patient-centred consultations.
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http://dx.doi.org/10.1111/ijcp.13907DOI Listing
April 2021

The Anatomy, Presentation and Management Options of Cubital Tunnel Syndrome.

J Hand Surg Asian Pac Vol 2020 Dec;25(4):393-401

Department of Orthopaedic Surgery, Royal Wolverhampton NHS Trust, Wolverhampton, UK.

Cubital tunnel syndrome is the second most common nerve compression syndrome seen in the upper limb. Paresthesia and weakness are the two most common presentations in the hand. If left untreated, compression can lead to irreversible nerve damage, resulting in a loss of function of the forearm and hand. Therefore, recognizing the various clinical presentations of cubital tunnel syndrome can lead to early detection and prevention of nerve damage. Conservative management is usually tried first and involves supporting the elbow using a splint. If this fails and symptoms do not improve, surgical management is indicated. There are 3 main surgical techniques used to relieve compression of the nerve. These are simple decompression, anterior transposition and medial epicondylectomy. Studies comparing the techniques have demonstrated particular advantages to using one or another. However, the overall technique of choice is based on both the clinical scenario and the surgeon's digression. Following primary cubital tunnel surgery, recurrent symptoms can often occur due to a variety of pathological and non-pathological causes and revision surgery is usually warranted. This article provides a complete review of cubital tunnel syndrome.
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http://dx.doi.org/10.1142/S2424835520400032DOI Listing
December 2020

Comparing Surgeon Adherence with World Health Organization Antiseptic Guidelines for Surgical Site Preparation in the United Kingdom and India.

Surg Infect (Larchmt) 2020 Sep 17;21(7):634-638. Epub 2020 Jun 17.

Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom.

Skin preparation with an antiseptic solution aims to reduce surgical site infection rates. Surgical site infections (SSIs) create a high burden on healthcare systems with impacts on morbidity, mortality, and cost. In 2016, The World Health Organization (WHO) conducted an extensive systematic review and meta-analysis of the existing evidence. From this, they recommended the use of "alcohol based antiseptic solutions based on CHG for surgical site skin preparation in patients undergoing surgical procedures." This study aimed to assess surgeon compliance with this guidance in the United Kingdom and India. A multiple-choice questionnaire was developed to assess surgeon preferences for antiseptic use in their surgical site preparation. The end point of data collection was defined after 50 responses in each region. The majority of respondents in each center was general surgeons (n = 24, 48% United Kingdom; n = 21, 45% India), and registrars (n = 22, 44% United Kingdom; n = 23, 49% India). No surgeon preferred the use of any aqueous preparation. Chlorhexidine gluconate (CHG) was the preparation used most commonly in both centers (n = 30, 64% India; n = 24, 48% United Kingdom). In India, this represented a statistically significant difference (p = 0.0008), however, this was not observed in the United Kingdom (p = 0.22). There were no statistically significant differences between surgeon's reasons between the United Kingdom and India, other than "easier to see" (p = 0.016). This data show a reduced compliance of U.K. surgeons with WHO guidance for antiseptic use compared with Indian surgeons. Although the WHO has attempted to summarize the existing data to minimize the previous uncertainty surrounding antiseptic choices, the use of CHG continues to not be adopted widely. To draw robust conclusions to provide the foundations of further guidelines, future research should focus on prospective randomized controlled trials with large numbers across multiple surgical specialties.
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http://dx.doi.org/10.1089/sur.2020.084DOI Listing
September 2020

Vestibular Schwannoma: What We Know and Where We are Heading.

Head Neck Pathol 2020 Dec 30;14(4):1058-1066. Epub 2020 Mar 30.

Royal Wolverhampton NHS Trust, Wolverhampton, WV10 0QP, UK.

Vestibular schwannoma (VS) is a Schwann cell-derived tumour arising from the vestibulocochlear nerve. Although benign, it represents a threat to intracranial structures due to mass effect and carries a small risk of malignant transformation. VS therefore represents an important healthcare burden. We review the literature regarding pathogenesis, risk factors, and diagnosis of VS. The current and future potential management strategies are also discussed. A narrative review of all relevant papers known to the authors was conducted. The majority of VS remain clinically stable and do not require interventional procedures. Nevertheless, various surgical techniques exist for removing VS, the most common of which are translabyrinthine and retrosigmoid approaches. Due to surgical risks such as hearing loss, facial nerve dysfunction, post-operative headache, and cerebrospinal fluid leakage, a "watch and rescan" approach is adopted for most patients. Radiotherapy is a useful alternative and has been shown to have a similar response for growth restriction. Due to the heterogeneous nature of VS, there is a lack of consensus regarding management of tumours that are too large for conservative management but too small to indicate surgery. Emerging biologic therapies, such as Bevacizumab, Everolimus, and Lapatinib, as well as anti-inflammatories like aspirin are promising potential treatments; however, long-term evidence of their efficacy is required. The knowledge base regarding VS continues to improve. With increased understanding of the pathogenesis of these tumors, we believe future work should focus on pharmacologic intervention. Biologic therapies aimed toward improved patient outcomes are particularly promising.
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http://dx.doi.org/10.1007/s12105-020-01155-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7669921PMC
December 2020

Ovarian cancer: screening and future directions.

Int J Gynecol Cancer 2019 01;29(1):195-200

Levine Cancer Institute, Charlotte, North Carolina, USA.

Ovarian cancer carries a lifetime risk of approximately 2% for women and is the leading cause of death from any gynecologic malignancy. Currently, no screening program for ovarian cancer exists for the general population in the UK. This review focuses on the evidence surrounding the efficacy of current markers and discusses future improvements in screening for this disease. One-off cancer antigen 125 (CA125) measurements for detecting ovarian cancer have been well researched. However, studies have highlighted low positive predictive values (5%) and high false positive rates leading to patient anxiety and unnecessary invasive follow-up. Commonly, in the UK, CA125 is combined with transvaginal ultrasound, but there is little evidence that this approach can decrease mortality from ovarian cancer. Recently the Risk of Ovarian Cancer Algorithm, involving a combination of serial CA125 measurements and age, has been shown to detect more early stage cancers. Nevertheless, these measures are not robust in decreasing mortality from ovarian cancer and are costly to implement. Newer markers, such as human epididymis protein 4, have shown greater specificity. Its combination with CA125 and menopausal status in the Risk of Ovarian Malignancy Algorithm can predict the risk of malignancy but provides no additional benefit as a screening tool. Advanced techniques are emerging, including ultrasound molecular imaging techniques using microbubbles targeted to kinase domain receptors, and fallopian tube cytology. To reduce mortality from ovarian cancer, detection of pre-invasive lesions is imperative as ovarian cancer may develop in the fallopian tube and spread to the peritoneal cavity before being detected systemically. It seems that screening tools for ovarian cancer are currently not worthwhile for implementation into a national program. An emphasis on reducing false positives rates, associated anxiety and subsequent overdiagnosis is needed.
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http://dx.doi.org/10.1136/ijgc-2018-000016DOI Listing
January 2019

Pharmacological Options in Atherosclerosis: A Review of the Existing Evidence.

Cardiol Ther 2019 Jun 12;8(1):5-20. Epub 2018 Dec 12.

Department of Public Health, Sandwell and West Birmingham NHS Trust, Birmingham, UK.

Coronary heart disease (CHD) is the leading cause of mortality worldwide and high low-density lipoprotein (LDL) cholesterol levels have been shown to be key in the pathogenesis of this condition. Lipid control has therefore been the subject of decades of research and has led to many large and robust randomized controlled trials, as well as the highest grossing drug of all time-Lipitor (atorvastatin). Statin therapy has long been indicated for secondary and more recently primary prevention. However, despite the large-scale use of statins, CHD prevalence remains high, and some patients do not respond to statin therapy. There has been a large push to find and test alternative lipid-lowering agents, these include fibrates, cholesterol absorption inhibitors, and proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitors. It is the aim of this review to assess the literature surrounding each of these groups of drugs.
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http://dx.doi.org/10.1007/s40119-018-0123-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6525235PMC
June 2019

Prognostic Value of Thyroid Profile in Critical Care Condition.

Indian J Endocrinol Metab 2018 May-Jun;22(3):387-391

Department of Endocrinology, LLRM Medical College, Meerut, Uttar Pradesh, India.

Background: Patients suffering from critical illness admitted to the Intensive Care Unit (ICU) exhibit alterations in their thyroid hormone levels, collectively termed as euthyroid sick syndrome or nonthyroidal illness syndrome. Our study was conducted to determine the correlation between these changes in thyroid hormone levels and the prognosis of ICU-admitted patients.

Methods: A total of 270 ICU-admitted patients without previous history of thyroid disorder were included in the study. We recorded their baseline characteristics, acute physiology and chronic health evaluation (APACHE-II) score, thyroid hormone levels, lactate, and other parameters on admission. ICU mortality was the primary outcome. We analyzed the ability of each parameter to predict mortality in the participants. Further, we also evaluated whether the combination of thyroid hormone levels with APACHE-II score could improve the mortality prediction.

Results: The mean age of the study population was 38.99 ± 18.32 years. A total of 81 patients (30%) expired during their ICU treatment. Both fT3 and fT4 levels were lower in nonsurvivors compared to survivors. Among the thyroid hormones, fT3 had the highest predictive value for ICU mortality, as seen by the largest area under the curve (AUC) value (0.990 ± 0.007) which was even greater than AUC of APACHE-II score (0.824 ± 0.051) and fT4 (0.917 ± 0.049). Univariate logistic regression analysis showed that fT3 (β = 140.560) had the highest predictive potential for ICU mortality compared with APACHE-II score (β = 0.776), fT4 (β = 17.62) and other parameters. Multivariate logistic regression analysis revealed that the combination of fT3 and APACHE-II (R = 0.652) was superior in predicting mortality than APACHE-II alone (R = 0.286).

Conclusion: We observed that fT3 was the strongest predictor of ICU mortality compared to all other parameters included in our study. Further, the combination of fT3 levels and APACHE-II scores provided for a higher probability for predicting mortality in ICU patients.
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http://dx.doi.org/10.4103/ijem.IJEM_20_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063192PMC
August 2018

Van Wyk-Grumbach Syndrome with Kocher-Debré-Sémélaigne Syndrome: Case Report of a Rare Association.

Eur Thyroid J 2017 Feb 4;6(1):47-51. Epub 2016 Oct 4.

Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India.

Background: Van Wyk-Grumbach syndrome (VWGS) is a rare presentation of juvenile hypothyroidism which manifests in females as chronic autoimmune hypothyroidism, isosexual pseudoprecocious puberty, and multicystic ovaries. It uniquely presents with short stature and delayed bone age unlike other causes of precocious puberty. Kocher-Debré-Sémélaigne (KDSS) is a rare presentation of juvenile hypothyroidism manifesting as calf muscle pseudohypertrophy, delayed contraction and relaxation of reflexes, and percussion myxedema.

Objectives: To diagnose the rare association of VWGS and KDSS and to conduct a follow-up of the patient on replacement therapy.

Methods: We present a case of a 9-year-old female child who presented to the endocrine department with complaints of intermittent vaginal bleeding, short stature, and difficulty in walking. On evaluation she was found to be having autoimmune hypothyroidism, FSH-dominated isosexual pseudoprecocious puberty, delayed bone age, secondary pituitary macroadenoma, delayed relaxation of deep tendon reflexes, and pseudohypertrophy of calf muscles. The diagnosis of VWGS associated with KDSS was made. The patient was initially put on 25 μg thyroxine replacement, which was titrated accordingly, and was followed up after 6 months and 1 year.

Results: All the features of the syndrome improved after 12 months of adequate thyroxine replacement.

Conclusions: VWGS and KDSS are rare presentations of juvenile hypothyroidism, and their association is even rarer. Early diagnosis and prompt replacement therapy can avoid unnecessary investigations and surgical interventions.
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http://dx.doi.org/10.1159/000448993DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5465749PMC
February 2017

Synthesis and biological evaluation of oxindole linked indolyl-pyrimidine derivatives as potential cytotoxic agents.

Bioorg Med Chem Lett 2016 07 7;26(13):3024-3028. Epub 2016 May 7.

Department of Medicinal Chemistry, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad 500 037, India. Electronic address:

In our endeavor towards the development of effective cytotoxic agents, a series of oxindole linked indolyl-pyrimidine derivatives were synthesized and characterized by IR, (1)H NMR, (13)C NMR and Mass spectral analysis. All the newly synthesized target compounds were assessed against PA-1 (ovarian), U-87MG (glioblastoma), LnCaP (prostate), and MCF-7 (Breast) cancer cell lines for their cytotoxic potential, with majority of them showing inhibitory activity at low micro-molar concentrations. Significantly, compound 8e was found to be most potent amongst all the tested compounds with an IC50 value of (2.43±0.29μM) on PA-1 cells. The influence of the most active cytotoxic compound 8e on the cell cycle distribution was assessed on the PA-1 cell line, exhibiting a cell cycle arrest at the G2/M phase. Moreover, acridine orange/ethidium bromide staining and annexin V binding assay confirmed that compound 8e can induce cell apoptosis in PA-1 cells. These preliminary results persuade further investigation on the synthesized compounds aiming to the development of potential cytotoxic agents.
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http://dx.doi.org/10.1016/j.bmcl.2016.05.019DOI Listing
July 2016

Cerebrotendinous xanthomatosis (a rare lipid storage disorder): a case report.

J Med Case Rep 2016 Apr 19;10(1):103. Epub 2016 Apr 19.

Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, 202002, Uttar Pradesh, India.

Background: Cerebrotendinous xanthomatosis is a very rare autosomal recessive lipid storage disorder affecting bile acid biosynthesis. It is manifested by subtle neurological and non-neurological symptoms due to abnormal tissue lipid deposition. Diagnosis is usually delayed but early diagnosis and replacement therapy can prevent devastating neurological sequelae.

Case Presentation: We present a case of a 25-year-old Asian Indian woman who presented with gait difficulty, fusiform swellings of bilateral tendo-Achilles and infrapatellar tendons, along with history of bilateral cataract surgery 1 year earlier. The diagnosis was made on the basis of clinical, biochemical, imaging, and histopathological analysis and replacement therapy was started.

Conclusions: The peculiarity of the present case is the absence of any neurological manifestations which are usually the early clues to the diagnosis of cerebrotendinous xanthomatosis. The present case report emphasizes the fact that early age bilateral cataracts along with bilateral tendo-Achilles xanthomas can be early pointers toward the diagnosis of cerebrotendinous xanthomatosis.
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http://dx.doi.org/10.1186/s13256-016-0882-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4837582PMC
April 2016

Diabetes mellitus: Trends in northern India.

Indian J Endocrinol Metab 2014 Sep;18(5):731-4

Department of Endocrinology, Lala Lajpat Rai Memorial Medical College, Meerut, Uttar Pradesh, India.

Diabetes mellitus is becoming a global health issue with more than 80% diabetics living in developing countries. India accounts for 62.4 million diabetics (2011). Indian Council of Medical Research India Diabetes Study (ICMR-INDIAB) study showed highest weighted prevalence rate in the north India among all studied regions. Diabetes in north India has many peculiarities in all aspects from risk factors to control programmers. North Indians are becoming more prone for diabetes and dyslipidemia because rapid westernization of living style and diet due rapid migration to metropolitan cities for employment. North Indian diabetes is plagued with gender bias against females, poor quality of health services, myths, and lack of disease awareness compounded with small number of prevention and awareness programmers that too are immature to counteract the growing pandemic.
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http://dx.doi.org/10.4103/2230-8210.139219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4171901PMC
September 2014

Pituitary stalk interruption syndrome: Case report of three cases with review of literature.

J Pediatr Neurosci 2014 May;9(2):188-91

Department of Endocrinology, LLRM Medical College, Meerut, India.

Pickardt syndrome (Pickardt-Fahlbusch syndrome) is a rare congenital syndrome characterized by tertiary hypothyroidism caused by the interruption of the portal veins between hypothalamus and adenohypophysis. Typical features of this syndrome are tertiary hypothyroidism with low thyroid stimulating hormone, hyperprolactinemia and other pituitary hormone deficiencies. Pituitary stalk interruption syndrome is characterized by a triad of thin or interrupted pituitary stalk, aplasia or hypoplasia of the anterior pituitary and absent or ectopic posterior pituitary (EPP) seen on magnetic resonance imaging (MRI). It is a congenital anomaly of pituitary whose exact prevalence is unknown. In some cases, it is restricted to EPP or pituitary stalk interruption. We are presenting the case history along with MRI finding of three children's who presented with short stature and delayed puberty.
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http://dx.doi.org/10.4103/1817-1745.139363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4166852PMC
May 2014

Thyroid acropachy: Frequently overlooked finding.

Indian J Endocrinol Metab 2014 Jul;18(4):590-1

Department of Endocrinology, Lala Lajpat Rai Memorial Medical College, Meerut, Uttar Pradesh, India.

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http://dx.doi.org/10.4103/2230-8210.137507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4138926PMC
July 2014

Correlation between liver fat content with dyslipidemia and Insulin resistance.

Indian J Endocrinol Metab 2013 Oct;17(Suppl 1):S355-7

Department of Endocrinology, Lala Lajpat Rai Memorial Medical College, Meerut, Uttar Pradesh, India.

Total 33 obese patients were studied to determine correlation in between liver fat content with dyslipidemia and insulin resistance. Liver and spleen attenuation measurements were taken with three regions of interests (ROIs) from the liver and two ROIs from the spleen. Hepatic attenuation indices were measured as follows: (1) Hepatic parenchymal attenuation (CTLP); (2) liver to spleen attenuation ratio (LSratio); and (3) difference between hepatic and splenic attenuation (LSdif). Bivariate correlation analysis showed moderate but statistically significant negative correlation between CTLP, LSratio, and LSdif with body mass index, triglyceride, fasting plasma sugar, fasting plasma insulin, homeostasis model assessment-insulin resistance (HOMA IR), 2 h oral glucose tolerance test (OGTT), and statistically significant positive correlation with high density lipoprotein. Nonalcoholic fatty liver disease (NAFLD) is closely associated with features of the metabolic syndrome. The amount of intrahepatic fat closely correlates with the number of metabolic syndrome features. The values of CTLP, LSratio, and LSdif demonstrate strong inverse correlations with degree of steatosis.
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http://dx.doi.org/10.4103/2230-8210.119620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3830359PMC
October 2013

Association of serum lipids with diabetic retinopathy in type 2 diabetes.

Indian J Endocrinol Metab 2013 Oct;17(Suppl 1):S335-7

Department of Ophthalmology, Subharti Medical College, Meerut, India.

A total number of 140 type 2 diabetic patients with diabetic retinopathy (DR) were enrolled in the study from diabetic clinic during May 2011 till June 2012 to determine correlation between severity of DR with serum lipid and other modifiable risk factors in type 2 diabetic patients. Information including age, sex, height, body weight, body mass index (BMI), waist-hip ratio (WHR), and systolic and diastolic blood pressure was collected from each patient. Fasting plasma sugar, low density lipoprotein (LDL), triglyceride level (TG), high density lipoprotein (HDL), glycated hemoglobin (HbA1C), creatinine, and 24 h urinary albumin excretion was done for each patient. Estimated glomerular filtration rate (eGFR) was measured by modification of diet in renal disease (MDRD) equation. Patients were divided in five groups according to retinopathy status based on early treatment DR study (ETDRS) disease severity level. Statistical analysis was performed with Statistical Packages for Social Sciences (SPSS) statistical software (version 17.0 for Windows). The alpha level was set at P = 0.05 for all tests. Statistically significant positive correlation between severity of DR with systolic blood pressure P = 0.005 (r = 0.974), diastolic blood pressure P = 0.001(r = 0.994), LDL P = 0.005 (r = 0.976), TG P = 0.001 (r = 0.990), and 24 h urinary albumin P = 0.004 (r = 0.977) was documented. DR was also strongly positively correlated with smoking P = 0.017 (r = 0.941) and duration of diabetes P = 0.003 (r = 0.981). There was strong inverse correlation of DR with HDL P = 0.001 (r = -0.994) and eGFR P = 0.002 (r = -0.987). Serum lipids were significantly correlated with severity of DR.
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http://dx.doi.org/10.4103/2230-8210.119637DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3830352PMC
October 2013

Re-emergence of a rare syndrome: A case of mauriac syndrome.

Indian J Endocrinol Metab 2013 Oct;17(Suppl 1):S283-5

Department of Endocrinology, Lala Lajpat Rai Memorial Medical College, Meerut, Uttar Pradesh, India.

Mauriac syndrome is a rare syndrome associated with type 1 diabetes (T1DM) in children presenting with growth retardation, hepatomegaly, and cushingoid features. Recently, there has been re-emergence of this syndrome, especially with the use of premix insulin. A 15-year old type 1 diabetic boy, who was on premix insulin with erratic blood glucose, was referred to us for evaluation of short stature. He had significant short stature, hepatomegaly, and cushingoid features. His growth hormone (GH) stimulation was normal, and so was the overnight dexamethasone suppression test, based on which the diagnosis of Mauriac syndrome was reported. He was made to switch over to basal bolus regime, and was advised to follow-up for 6 months. He had reduction in hepatomegaly and a height gain of 3 cms.
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http://dx.doi.org/10.4103/2230-8210.119611DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3830333PMC
October 2013
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