Publications by authors named "Pankaj Garg"

499 Publications

Mass urine sugar testing to tackle post-COVID mucormycosis epidemic in India-MUSTARD concept.

Diabetes Metab Syndr 2021 Jun 18;15(4):102177. Epub 2021 Jun 18.

Oral & Maxillofacial Surgeon, Mittal Dental Clinic, Jaipur, India.

Background: Post-Covid mucormycosis is associated with very high morbidity and reasonably high mortality. The three main causes seem to be covid infection, excessive steroid usage and uncontrolled diabetes.

Methods: Of the three risk factors causing post-Covid mucormycosis, the only risk factor which can be modified quickly is uncontrolled diabetes. Checking urine-sugar levels of susceptible population asymptomatic for mucormycosis can be done rapidly and at a relatively low cost. Urine sugar positive persons can then be investigated and managed for uncontrolled diabetes.

Results: None CONCLUSIONS: Mass urine sugar testing to assess and regulate diabetes(MUSTARD) can help identify and manage uncontrolled diabetes in populations with high prevalence of diabetes.
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http://dx.doi.org/10.1016/j.dsx.2021.06.014DOI Listing
June 2021

Macronutrient analysis of human milk and factors associated with its composition in mothers of preterm infants ≤ 32 weeks.

Eur J Pediatr 2021 Jun 18. Epub 2021 Jun 18.

Department of Dietetics, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110060, India.

We conducted an exploratory longitudinal study to evaluate the macronutrient composition of human milk in mothers delivering very preterm infants ≤ 32 weeks over the first 4 weeks of lactation and the association of human milk composition with maternal and neonatal factors A total of 213 human milk samples collected in the morning between 8 am and 12 pm from 60 eligible mothers were analyzed on 7 (n = 60), 14 (n = 60), 21 (n = 52), and 28 (n = 41) days of lactation by infrared transmission spectroscopy. The true protein content decreased significantly over 4 weeks (mean difference (95% confidence interval)) (MD (95% CI)) week 1 and week 4 = 0.2 g (0.037 to 0.363, P = 0.009)). On the contrary, the mean fat and calorie content showed significant increase over time (MD (95% CI)) = - 1.03 g (- 1.719 to - 0.343, P = 0.001) and - 9.0 kcal/dl (- 15.170 to - 2.830, P = 0.001), respectively). There was no difference in the carbohydrate content of human milk over 4 weeks. Macronutrient composition was independent of maternal parity, mode of delivery, pre-pregnancy body mass index, umbilical artery Doppler flows, previous breast feeding experience, neonatal centile status, gestation, and infant's weight at birth. Multiple regression analysis of human milk composition with mother's dietary components showed no significant association. CONCLUSION : We conclude that in mothers who deliver very preterm infants ≤ 32 weeks, true protein content decreased, fat and calorie content increased, and carbohydrate content remained stable in human milk during first 4 weeks of lactation. Human milk macronutrient composition was independent of various maternal and neonatal factors including maternal body mass index and dietary intake. TRIAL REGISTRATION : CTRI/2017/02/007895 What is Known: • Preterm human milk has high temporal and inter-individual variation in the macronutrient composition. What is New: • In mothers who deliver very preterm infants < 32 weeks, true protein content decreases, fat and calorie content increases, and carbohydrate content remains stable in human milk during first 4 weeks of lactation. • Human milk macronutrient composition is independent of various maternal and neonatal factors including maternal body mass index and dietary intake.
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http://dx.doi.org/10.1007/s00431-021-04158-0DOI Listing
June 2021

Amplitude integrated EEG: how much it helps in prognostication in neonatal encephalopathy?

J Matern Fetal Neonatal Med 2021 Jun 13:1-8. Epub 2021 Jun 13.

Sir Ganga Ram Hospital, New Delhi, India.

Introduction: Neonatal encephalopathy (NE) is associated with a high risk of adverse neurological outcomes. Several neurodiagnostic tests have been evaluated to predict the prognosis. Amplitude integrated Electroencephalogram (aEEG) is now being commonly used for bedside evaluation of cerebral function. There is limited data on the role of aEEG for prognostication in NE, from resource-limited settings.

Objective: To evaluate the predictive ability of aEEG for abnormal neurological outcomes in neonatal encephalopathy or neonates with encephalopathy.

Methods: Neonates above 35 weeks of gestation admitted to NICU in a tertiary care hospital with a diagnosis of encephalopathy were enrolled. Clinical characteristics severity of encephalopathy and seizures were recorded. Amplitude integrated recording was started at admission and continued till recovery of trace to normal or for 10 days. The primary outcome was death or abnormal neurological status at 3-6 months of age. The study was registered in the Clinical Trial Registry of India (CTRI/2013/05/003612).

Results: The incidence of NE was 6% of total admission. Moderate and severe encephalopathy occurred in 58 and 39% of babies respectively. Hypoxic-ischemic encephalopathy was the most common cause. Clinical seizures occurred in 91% of cases. An abnormal aEEG trace was observed in 51 (76.1%) infants with NE. For adverse neurological outcomes at an age average of 4.5 months of age, aEEG had a sensitivity, specificity, NPV, and PPV of 100, 54.2, 100, and 77.5, respectively.

Conclusions: Clinical staging and aEEG has good predictive ability to detect an adverse neurological outcome. aEEG improves the ability to predict abnormal outcome in babies with moderate encephalopathy. Early recovery of aEEG abnormality correlates with better neurodevelopmental outcomes.KEY MESSAGES: aEEG is a useful modality to assess neurodevelopmental outcomes however data from developing countries is lacking.: aEEG monitoring in babies in neonatal encephalopathy may improve the prediction of abnormal neurological outcomes in babies with moderate encephalopathy.
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http://dx.doi.org/10.1080/14767058.2021.1937104DOI Listing
June 2021

Early diagnosis of diaphragm palsy after pediatric cardiac surgery and outcome after diaphragm plication - A single-center experience.

Ann Pediatr Cardiol 2021 Apr-Jun;14(2):178-186. Epub 2021 Feb 16.

Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India.

Objective: The aims of our prospective observational study were to evaluate the (1) reliability of clinical signs in the early detection of diaphragm palsy (DP); (2) reliability of ultrasonography using echo machine as a bedside tool for the diagnosis of DP; and (3) does early diaphragm plication result in the improved outcome? We also sought to determine the incidence and predominant risk factors for DP and diaphragm plication at our center.

Materials And Methods: This prospective observational study included patients with suspected DP from January 2015 to December 2018. Patients with suspected DP were initially evaluated by bedside ultrasonography using echo machine and confirmed by fluoroscopy. Diaphragm plication was considered for patients having respiratory distress, difficult weaning, or failed extubation attempt without any obvious cardiac or pulmonary etiology. Patients were followed for 3 months after discharge to assess diaphragm function.

Results: A total of 87 patients were suspected of DP based on clinical signs. DP was diagnosed in 61 patients on fluoroscopy. The median time from index operation to diagnosis was 10 (1-59) days. Diaphragm plication was done among 52 patients and not done in nine patients. Bedside ultrasonography using echo machine was 96.7% sensitive and 96.15% specific in diagnosing DP. Early plication (<14 days) significantly reduced the need for nasal continuous positive airway pressure (65% vs. 96%, = 0.02), duration of mechanical ventilation (12 vs. 25 days, = 0.018), intensive care unit (ICU) stay (25 days vs. 39 days, = 0.019), and hospital stay (30 days vs. 46 days, = 0.036).

Conclusion: Hoover's sign and raised hemidiaphragm on chest X-ray are the most specific clinical signs to suspect unilateral DP. Bedside ultrasonography using an echo machine is a good diagnostic investigation comparable to fluoroscopy. Early plication facilitates weaning from the ventilator and thereby decreases the ICU stay and hospital stay.
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http://dx.doi.org/10.4103/apc.APC_171_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174623PMC
February 2021

Feasibility and validation of trans-valvular flow derived by four-dimensional flow cardiovascular magnetic resonance imaging in patients with atrial fibrillation.

Wellcome Open Res 2021 18;6:73. Epub 2021 May 18.

Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK.

: Four-dimensional (4D) flow cardiovascular magnetic resonance imaging (MRI) is an emerging technique used for intra-cardiac blood flow assessment. The role of 4D flow cardiovascular MRI in the assessment of trans-valvular flow in patients with atrial fibrillation (AF) has not previously been assessed. The purpose of this study was to assess the feasibility, image quality, and internal validity of 4D flow cardiovascular MRI in the quantification of trans-valvular flow in patients with AF. : Patients with AF and healthy controls in sinus rhythm underwent cardiovascular MRI, including 4D flow studies. Quality assurance checks were done on the raw data and streamlines. Consistency was investigated by trans-valvular flow assessment between the mitral valve (MV) and the aortic valve (AV). : Eight patients with AF (88% male, mean age 62±13 years, mean heart rate (HR) 83±16 beats per minute (bpm)) were included and compared with ten healthy controls (70% male, mean age 41±20 years, mean HR 68.5±9 bpm). All scans were of either good quality with minimal blurring artefacts, or excellent quality with no artefacts. No significant bias was observed between the AV and MV stroke volumes in either healthy controls (-4.8, 95% CI -15.64 to 6.04; P=0.34) or in patients with AF (1.64, 95% CI -4.7 to 7.94; P=0.56). A significant correlation was demonstrated between MV and AV stroke volumes in both healthy controls (r=0.87, 95% CI 0.52 to 0.97; P=0.001) and in AF patients (r=0.82, 95% CI 0.26 to 0.97; P=0.01). : In patients with AF, 4D flow cardiovascular MRI is feasible with good image quality, allowing for quantification of trans-valvular flow.
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http://dx.doi.org/10.12688/wellcomeopenres.16655.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8150120PMC
May 2021

Secondary cytoreduction for relapsed ovarian cancer.

Lancet Oncol 2021 06;22(6):e230

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh 249203, India.

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http://dx.doi.org/10.1016/S1470-2045(21)00181-9DOI Listing
June 2021

Biomarkers Associated with Mortality in Aortic Stenosis: A Systematic Review and Meta-Analysis.

Med Sci (Basel) 2021 May 17;9(2). Epub 2021 May 17.

Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, UK.

The optimal timing of aortic valve replacement (AVR) remains controversial. Several biomarkers reflect the underlying pathophysiological processes in aortic stenosis (AS) and may be of use as mortality predictors. The aim of this systematic review and meta-analysis is to evaluate the blood biomarkers utilised in AS and assess whether they associate with mortality. PubMed and Embase were searched for studies reporting baseline biomarker level and mortality outcomes in patients with AS. A total of 83 studies met the inclusion criteria and were systematically reviewed. Of these, 21 reporting brain natriuretic peptide (BNP), N-terminal pro B-type natriuretic peptide (NT-proBNP), Troponin and Galectin-3 were meta-analysed. Pooled analysis demonstrated that all-cause mortality was significantly associated with elevated baseline levels of BNP (HR 2.59; 95% CI 1.95-3.44; < 0.00001), NT-proBNP (HR 1.73; 95% CI 1.45-2.06; = 0.00001), Troponin (HR 1.65; 95% CI 1.31-2.07; < 0.0001) and Galectin-3 (HR 1.82; 95% CI 1.27-2.61; < 0.001) compared to lower baseline biomarker levels. Elevated levels of baseline BNP, NT-proBNP, Troponin and Galectin-3 were associated with increased all-cause mortality in a population of patients with AS. Therefore, a change in biomarker level could be considered to refine optimal timing of intervention. The results of this meta-analysis highlight the importance of biomarkers in risk stratification of AS, regardless of symptom status.
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http://dx.doi.org/10.3390/medsci9020029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8163007PMC
May 2021

Migration of biliary stent into the gallbladder: A surprising intraoperative finding.

J Minim Access Surg 2021 May 18. Epub 2021 May 18.

Department of Surgery, SSR Medical College, Belle Rive, Mauritius.

Post-endoscopic retrograde cholangiopancreatography stenting is a well-established treatment for benign as well as malignant biliary obstruction. The most frequently encountered complication is stent clogging. Stent migration (proximal or distal), on the other hand, is not very common. Proximal migration of a choledochal endoprosthesis into the gallbladder has not yet been reported in the literature.
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http://dx.doi.org/10.4103/jmas.JMAS_47_21DOI Listing
May 2021

Impact of age, sex and ethnicity on intra-cardiac flow components and left ventricular kinetic energy derived from 4D flow CMR.

Int J Cardiol 2021 08 25;336:105-112. Epub 2021 May 25.

National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Drive, 169609, Singapore; Duke-NUS Medical School, National University of Singapore, 8 College Road, 169857, Singapore. Electronic address:

Background: Four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) allows quantification of left ventricular (LV) blood flow. We aimed to 1) establish reference ranges for 4D flow CMR-derived LV relative flow components and kinetic energy parameters indexed to end-diastolic volume (KEi) among healthy Asian subjects, 2) assess effects of age and sex on these parameters, and 3) compare these parameters between Asian and Caucasian subjects.

Methods: 74 healthy Asian subjects underwent cine and 4D flow CMR. Relative flow components (direct flow, retained inflow, delayed ejection flow, residual volume) and multiple phasic KEi (LV global, peak systolic, systolic, diastolic, peak E-wave, peak A-wave) were analyzed. Sex- and age-specific reference ranges were reported.

Results: Relative flow components and systolic phase KEi did not vary with age. Women had higher retained inflow and peak E-wave KEi, lower residual volume, peak systolic and systolic KEi than men. Peak A-wave KEi increased significantly (r = 0.474) whereas peak E-wave KEi (r = -0.458) and E-wave/A-wave ratio (r = -0.528) decreased with age. A sub-population (n = 44) was compared with 44 sex- and age-matched Caucasian subjects: no significant group differences were observed for all 4D flow CMR parameters.

Conclusion: Asian sex- and age-specific 4D flow CMR reference ranges were established. Sex differences in retained inflow, residual volume, peak systolic, systolic KEi and peak E-wave KEi were observed. Ageing influenced diastolic KEi but not systolic phase KEi or relative flow components. All studied parameters were similar between sex- and age-matched Asian and Caucasian subjects, implying generalizability of the ranges.
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http://dx.doi.org/10.1016/j.ijcard.2021.05.035DOI Listing
August 2021

Detrimental Immediate- and Medium-Term Clinical Effects of Right Ventricular Pacing in Patients With Myocardial Fibrosis.

Circ Cardiovasc Imaging 2021 May 18;14(5):e012256. Epub 2021 May 18.

Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.E.D.S., M.F.P., L.A.E.B., J.G., P.G.C., A.D., T.P.C., A.C., A.K., E.L., E.D., K.K.W., J.P.G., S.P., P.P.S.).

Background: Long-term right ventricular (RV) pacing leads to heart failure or a decline in left ventricular (LV) function in up to a fifth of patients. We aimed to establish whether patients with focal fibrosis detected on late gadolinium enhancement cardiovascular magnetic resonance (CMR) have deterioration in LV function after RV pacing.

Methods: We recruited 84 patients with LV ejection fraction ≥40% into 2 observational CMR studies. Patients (n=34) with a dual-chamber device and preserved atrioventricular conduction underwent CMR in 2 asynchronous pacing modes (atrial asynchronous and dual-chamber asynchronous) to compare intrinsic atrioventricular conduction with forced RV pacing. Patients (n=50) with high-grade atrioventricular block underwent CMR before and 6 months after pacemaker implantation to investigate the medium-term effects of RV pacing.

Results: The key findings were (1) initiation of RV pacing in patients with fibrosis, compared with those without, was associated with greater immediate changes in both LV end-systolic volume index (5.3±3.5 versus 2.1±2.4 mL/m; <0.01) and LV ejection fraction (-5.7±3.4% versus -3.2±2.6%; =0.02); (2) medium-term RV pacing in patients with fibrosis, compared with those without, was associated with greater changes in LV end-systolic volume index (8.0±10.4 versus -0.6±7.3 mL/m; =0.008) and LV ejection fraction (-12.3±7.9% versus -6.7±6.2%; =0.012); (3) patients with fibrosis did not experience an improvement in quality of life, biomarkers, or functional class after pacemaker implantation; (4) after 6 months of RV pacing, 10 of 50 (20%) patients developed LV ejection fraction <35% and were eligible for upgrade to cardiac resynchronization according to current guidelines. All 10 patients had fibrosis on their preimplant baseline scan and were identified by >1.1 g of fibrosis with 90% sensitivity and 70% specificity.

Conclusions: Fibrosis detected on CMR is associated with immediate- and medium-term deterioration in LV function following RV pacing and could be used to identify those at risk of heart failure before pacemaker implantation.
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http://dx.doi.org/10.1161/CIRCIMAGING.120.012256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136461PMC
May 2021

Cardiovascular magnetic resonance predicts all-cause mortality in pulmonary hypertension associated with heart failure with preserved ejection fraction.

Int J Cardiovasc Imaging 2021 May 12. Epub 2021 May 12.

Sheffield Teaching Hospitals NHS Foundation Trust, London, England.

This study aimed to determine the prognostic value of cardiovascular magnetic resonance (CMR) in patients with heart failure with preserved ejection fraction and associated pulmonary hypertension (pulmonary hypertension-HFpEF). Patients with pulmonary hypertension-HFpEF were recruited from the ASPIRE registry and underwent right heart catheterisation (RHC) and CMR. On RHC, the inclusion criteria was a mean pulmonary artery pressure (MPAP) ≥ 25 mmHg and pulmonary arterial wedge pressure > 15 mmHg and, on CMR, a left atrial volume > 41 ml/m with left ventricular ejection fraction > 50%. Cox regression was performed to evaluate CMR against all-cause mortality. In this study, 116 patients with pulmonary hypertension-HFpEF were identified. Over a mean follow-up period of 3 ± 2 years, 61 patients with pulmonary hypertension-HFpEF died (53%). In univariate regression, 11 variables demonstrated association to mortality: indexed right ventricular (RV) volumes and stroke volume, right ventricular ejection fraction (RVEF), indexed RV mass, septal angle, pulmonary artery systolic/diastolic area and its relative area change. In multivariate regression, only three variables were independently associated with mortality: RVEF (HR 0.64, P < 0.001), indexed RV mass (HR 1.46, P < 0.001) and IV septal angle (HR 1.48, P < 0.001). Our CMR model had 0.76 area under the curve (P < 0.001) to predict mortality. This study confirms that pulmonary hypertension in patients with HFpEF is associated with a poor prognosis and we observe that CMR can risk stratify these patients and predict all-cause mortality. When patients with HFpEF develop pulmonary hypertension, CMR measures that reflect right ventricular afterload and function predict all-cause mortality.
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http://dx.doi.org/10.1007/s10554-021-02279-zDOI Listing
May 2021

Diagnosis of anorectal tuberculosis by polymerase chain reaction, GeneXpert and histopathology in 1336 samples in 776 anal fistula patients.

World J Gastrointest Surg 2021 Apr;13(4):355-365

Department of Statistics, Indian Council of Medical Research, New Delhi 110029, India.

Background: The association of tuberculosis (TB) with anal fistulas can make its treatment quite difficult. The main challenge is timely detection of TB in anal fistulas and its proper management. There is little data available on diagnosis and management of TB in anal fistulas.

Aim: To detect TB in fistula-in-ano patients were analyzed in different methods utilized.

Methods: A retrospective analysis of different methods, polymerase chain-reaction (PCR), GeneXpert and histopathology (HPE), utilized to detect tuberculosis in fistula-in-ano patients, treated between 2014-2020, was performed. The sampling was done for tissue (fistula tract lining) and pus (when available). The detection rate of various tests to detect TB and prevalence rate of TB in simple complex fistulae were studied.

Results: In 1336 samples (776 patients) tested, TB was detected in 133 samples (122 patients). TB was detected in 52/703 (7.4%) samples tested by PCR-tissue, in 77/331 (23.2%) samples tested by PCR-pus, 3/197 (1.5%) samples tested with HPE-tissue and 1/105 (0.9%) samples tested by GeneXpert. To detect TB, PCR-tissue was significantly better than HPE-tissue (52/703 3/197 respectively) ( = 0.0012, significant, Fisher's exact test) and PCR-pus was significantly better than PCR-tissue (77/331 52/703 respectively) ( < 0.00001, significant, Fisher's exact test). TB fistulas were more complex than non-tuberculous fistulas [78/113 (69%) 278/727 (44.3%) respectively] ( < 0.00001, significant, Fisher's exact test) but the overall healing rate was similar in tuberculous and non-tuberculous fistula groups [90/102 (88.2%) 518/556 (93.2%) respectively] ( = 0.10, not significant, Fisher's exact test).

Conclusion: This is the largest study of anorectal TB to be published. The detection of TB by polymerase chain-reaction was significantly higher than by histopathology and GeneXpert. Amongst polymerase chain-reaction, pus had a higher detection rate than tissue. TB fistulas were more complex than non-tuberculous fistulas but aggressive diagnosis and meticulous treatment led to comparable overall success rates in both groups.
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http://dx.doi.org/10.4240/wjgs.v13.i4.355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8069068PMC
April 2021

Lessons learned from an audit of 1250 anal fistula patients operated at a single center: A retrospective review.

World J Gastrointest Surg 2021 Apr;13(4):340-354

Department of Statistics, Indian Council of Medical Research, New Delhi 110029, New Delhi, India.

Background: A complex anal fistula is a challenging disease to manage.

Aim: To review the experience and insights gained in treating a large cohort of patients at an exclusive fistula center.

Methods: Anal fistulas operated on by a single surgeon over 14 years were analyzed. Preoperative magnetic resonance imaging was done in all patients. Four procedures were performed: fistulotomy; two novel sphincter-saving procedures, proximal superficial cauterization of the internal opening and regular emptying and curettage of fistula tracts (PERFACT) and transanal opening of intersphincteric space (TROPIS), and anal fistula plug. PERFACT was initiated before TROPIS. As per the institutional GFRI algorithm, fistulotomy was done in simple fistulas, and TROPIS was done in complex fistulas. Fistulas with associated abscesses were treated by definitive surgery. Incontinence was evaluated objectively by Vaizey incontinence scores.

Results: A total of 1351 anal fistula operations were performed in 1250 patients. The overall fistula healing rate was 19.4% in anal fistula plug ( = 56), 50.3% in PERFACT ( = 175), 86% in TROPIS ( = 408), and 98.6% in fistulotomy ( = 611) patients. Continence did not change significantly after surgery in any group. As per the new algorithm, 1019 patients were operated with either the fistulotomy or TROPIS procedure. The overall success rate was 93.5% in those patients. In a subgroup analysis, the overall healing rate in supralevator, horseshoe, and fistulas with an associated abscess was 82%, 85.8%, and 90.6%, respectively. The 90.6% healing rate in fistulas with an associated abscess was comparable to that of fistulas with no abscess (94.5%, = 0.057, not significant).

Conclusion: Fistulotomy had a high 98.6% healing rate in simple fistulas without deterioration of continence if the patient selection was done judiciously. The sphincter-sparing procedure, TROPIS, was safe, with a satisfactory 86% healing rate for complex fistulas. This is the largest anal fistula series to date.
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http://dx.doi.org/10.4240/wjgs.v13.i4.340DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8069067PMC
April 2021

Do we need evidence for evidence-based medicine?

J Eval Clin Pract 2021 May 8. Epub 2021 May 8.

Department of Surgical Oncology, All India Institute of Medical Sciences-Rishikesh, Rishikesh, Uttarakhand, India.

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http://dx.doi.org/10.1111/jep.13577DOI Listing
May 2021

Parents' and Service Providers' Experiences of Accessing Health Services from an Intellectual Disability Health Team.

J Prim Care Community Health 2021 Jan-Dec;12:21501327211014068

Sydney Children's Hospitals Network (Westmead), Westmead, NSW, Australia.

A pediatric assessment service for children with Intellectual Disability (ID) was established in a culturally diverse region of Sydney, Australia, to meet the health needs of children and young people with ID. This paper reports on parents' and providers' experiences using qualitative and quantitative analysis of surveys. The survey responses from the parents' enumerated their key concerns and the practical help they received from the service. Responses from service providers reported a high level of satisfaction with the services and valued the quality of assessment reports. The service facilitated inter-agency collaboration and enhanced the access to quality health care.
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http://dx.doi.org/10.1177/21501327211014068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8114321PMC
June 2021

Laying Open and Curettage under Local Anesthesia to Treat Pilonidal Sinus: Long-Term Follow-Up in 111 Consecutively Operated Patients.

Clin Pract 2021 Apr 1;11(2):193-199. Epub 2021 Apr 1.

Nishtha Surgical Hospital and Research Centre, Patan 384265, Gujarat, India.

(1) Background: Several techniques for the treatment of pilonidal sinus disease (PSD) are in vogue, though none have emerged as the gold standard. Laying open (deroofing) and curettage under local anesthesia is one of the most straightforward procedures to treat PSD. In this study, the long-term follow-up in a large series was analyzed. (2) Methods: The laying open approach was performed for all types of consecutive PSD patients-simple, complicated, and abscess. The primary outcome parameter of the study was the healing rate. The secondary outcome parameters were operating time, hospital stay, time to resumption of normal work, and healing time. (3) Results: 111 (M/F-92/19, mean age-22.9 ± 5.7 years) consecutive patients were operated on and followed for 38 months (6-111 months). Of these, 24 had pilonidal abscesses, 87 had chronic pilonidal disease, while 22 had recurrent disease. Operating time and hospital stay were 24 ± 7 min and 66 ± 23 min, respectively. On average, patients could resume normal work in 3.6 ± 2.9 days and the healing time was 43.8 ± 7.4 days. Three patients were lost to follow-up. Complete resolution of the disease occurred in 104/108 (96.3%) patients, while 4 (3.7%) had a recurrence. One recurrence was due to a missed tract, while three recurrences presented after complete healing had occurred. Two patients with recurrence were operated on again with the same procedure, and both healed completely. Thus, the overall success rate of this procedure was 98.1% (106/108) with a recurrence rate after first surgery of 3.7% over a median follow-up of 38 months. (4) Conclusions: Pilonidal disease managed by laying open (deroofing) with curettage under local anesthesia is associated with a high cure rate. This procedure is effective in treating all kinds of pilonidal disease (simple, complicated, and abscess).
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http://dx.doi.org/10.3390/clinpract11020028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8167585PMC
April 2021

Role of MRI to confirm healing in complex high cryptoglandular anal fistulas: long-term follow-up of 151 cases.

Colorectal Dis 2021 Apr 26. Epub 2021 Apr 26.

SSR Medical College, Belle Rive,, Mauritius.

Aim: Complex fistula-in-ano can recur even after complete clinical healing has occurred. 'Radiological healing' of fistula on MRI correlates well with long-term healing rates but no study has yet objectively quantified this. The aim of this study was to assess the accuracy of anal fistula healing as documented on MRI and to correlate it with long-term healing as evidenced on long-term follow-up.

Methods: Patients with clinically healed anal fistulas who also had radiological healing checked by postoperative MRI were included in the study.

Results: Three hundred and twenty-five patients operated for high complex fistula-in-ano were followed up for 14-68 months (median 38 months). Postoperative MRI was done to assess radiological healing of the fistula in 151 patients, and they were included in the study. The mean age was 39.4 ± 10.5 years (116 men). Five patients were lost to follow-up. The fistulas did not heal radiologically (on MRI) in 20 patients and recurred in all these patients. The fistulas healed radiologically (on MRI) in 126 patients. On long-term follow-up, 124/126 patients remained healed while 2/126 had a recurrence. In the first patient, the fistula recurred 40 months after complete radiological healing. In the second patient, the fistula recurred 10 months after complete radiological healing but pus from the fistula tested positive for tuberculosis (by real-time polymerase chain reaction) and he was excluded from the analysis. Thus, there was only one (1/125) recurrence on long-term follow-up.

Conclusions: Radiological healing on MRI correlates well with long-term healing in complex fistula-in-ano.
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http://dx.doi.org/10.1111/codi.15695DOI Listing
April 2021

Inflammation in Irritable Bowel Syndrome (IBS): Role of Psyllium Fiber Supplementation in Decreasing Inflammation and Physiological Management of IBS.

Authors:
Pankaj Garg

Turk J Gastroenterol 2021 01;32(1):108-110

Garg Fistula Research Institute, Panchkula, India; Indus International hospital, Mohali, India.

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http://dx.doi.org/10.5152/tjg.2020.20229DOI Listing
January 2021

Scabbard trachea in medullary thyroid cancer.

BMJ Case Rep 2021 Apr 23;14(4). Epub 2021 Apr 23.

Surgical Oncology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

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http://dx.doi.org/10.1136/bcr-2021-242352DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8074536PMC
April 2021

Comparison of different methods to manage supralevator rectal opening in anal fistulas: A retrospective cohort study.

Cir Esp (Engl Ed) 2021 Apr 16. Epub 2021 Apr 16.

SSRD MRI Centre, Chandigarh, India.

Introduction: Supralevator fistula-in-ano are difficult to manage. If these fistulas have an additional supralevator internal-opening in rectum apart from the primary internal-opening at the dentate line, then the management becomes even more difficult. There is no literature/guidelines available on the management of supralevator rectal opening (SRO).

Methods: All consecutive supralevator fistula-in-ano patients having a SRO were retrospectively analyzed. The operative management of SRO in these fistulas was reviewed. All the fistulas were managed by the same procedure, transanal opening of intersphincteric space (TROPIS). The latter was a modification of LIFT (ligation of intersphincteric tract) procedure in which the intersphincteric tract was opened-up in the rectum rather than ligated (as is done in LIFT). The SRO was managed in three ways, group-1:SRO was laid-open into the rectum in continuity with the primary opening at dentate line, group-2:the mucosa around SRO was cauterized, group-3:nothing could be done to SRO.

Results: Out of 836 patients operated between 2015 and 2020, 138 patients (16.5%) had supralevator extension. Amongst these, 23/138 (16.6%) patients had a SRO. 2 patients were excluded (short follow-up) and 21 patients were included in the analysis. 12/13(92%) patients in group-1, 4/5 (80%) patients in group-2 and 2/3(67%) patients in group-3 got healed (p=0.47, Chi-square test). The overall healing rate was 18/21(86%).

Conclusions: The supralevator rectal opening (SRO) heals well irrespective of the method utilized. Thus, proper management of the primary opening at the dentate line holds the key to fistula healing and SRO is perhaps not much responsible for persistence of the fistula. However, more studies are needed to corroborate these findings.
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http://dx.doi.org/10.1016/j.ciresp.2021.03.011DOI Listing
April 2021

The Efficacy of Transanal Opening of Intersphincteric Space Procedure in High Complex Anal Fistulas on Long-term Follow-up.

Am Surg 2021 Apr 13:31348211011092. Epub 2021 Apr 13.

Department of General Surgery, 552925Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, India.

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http://dx.doi.org/10.1177/00031348211011092DOI Listing
April 2021

Re: Small bowel perforation from migrated biliary stent: why did it happen?

ANZ J Surg 2021 04;91(4):762-763

Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, India.

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http://dx.doi.org/10.1111/ans.16520DOI Listing
April 2021

Re: Incarceration of a Meckel's diverticulum by jejunal diverticulosis: an atypical cause of small bowel obstruction.

ANZ J Surg 2021 04;91(4):761-762

Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, India.

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http://dx.doi.org/10.1111/ans.16499DOI Listing
April 2021

Re: Irreducible inguinal hernia and acute appendicitis: a case of Amyand's hernia.

ANZ J Surg 2021 04;91(4):762

Garg Fistula Research Institute, Department of Colorectal Surgery, Panchkula, India.

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http://dx.doi.org/10.1111/ans.16493DOI Listing
April 2021

Bleeding eyelid with a diagnostic dilemma.

BMJ Case Rep 2021 Apr 7;14(4). Epub 2021 Apr 7.

Surgical Oncology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

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http://dx.doi.org/10.1136/bcr-2021-242618DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8031021PMC
April 2021

Left ventricular blood flow kinetic energy is associated with the six-minute walk test and left ventricular remodelling post valvular intervention in aortic stenosis.

Quant Imaging Med Surg 2021 Apr;11(4):1470-1482

Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK.

Background: Left ventricular (LV) kinetic energy (KE) assessment by four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) may offer incremental value over routine assessment in aortic stenosis (AS). The main objective of this study is to investigate the LV KE in patients with AS before and after the valve intervention. In addition, this study aimed to investigate if LV KE offers incremental value for its association to the six-minute walk test (6MWT) or LV remodelling post-intervention.

Methods: We recruited 18 patients with severe AS. All patients underwent transthoracic echocardiography for mean pressure gradient (mPG), CMR including 4D flow and 6MWT. Patients were invited for post-valve intervention follow-up CMR at 3 months and twelve patients returned for follow-up CMR. KE assessment of LV blood flow and the components (direct, delayed, retained and residual) were carried out for all cases. LV KE parameters were normalised to LV end-diastolic volume (LVEDV).

Results: For LV blood flow KE assessment, the metrics including time delay (TD) for peak E-wave from base to mid-ventricle (14±48 2.5±9.75 ms, P=0.04), direct (4.91±5.07 1.86±1.72 µJ, P=0.01) and delayed (2.46±3.13 1.38±1.15 µJ, P=0.03) components of LV blood flow demonstrated a significant change between pre- and post-valve intervention. Only LV KEi (r=-0.53, P<0.01), diastolic KEi (r=-0.53, P<0.01) and E KEi (r=-0.38, P=0.04) demonstrated association to the 6MWT. However, Pre-operative LV KEi (r=0.67, P=0.02) demonstrated association to LV remodelling post valve intervention.

Conclusions: LV blood flow KE is associated with 6MWT and LV remodelling in patients with AS. LV KE assessment provides incremental value over routine LV function and pressure gradient (PG) assessment in AS.
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http://dx.doi.org/10.21037/qims-20-586DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930677PMC
April 2021

Association Between Renin-Angiotensin-Aldosterone System Inhibitors and Clinical Outcomes in Patients With COVID-19: A Systematic Review and Meta-analysis.

JAMA Netw Open 2021 03 1;4(3):e213594. Epub 2021 Mar 1.

Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom.

Importance: The chronic receipt of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) has been assumed to exacerbate complications associated with COVID-19 and produce worse clinical outcomes.

Objective: To conduct an updated and comprehensive systematic review and meta-analysis comparing mortality and severe adverse events (AEs) associated with receipt vs nonreceipt of ACEIs or ARBs among patients with COVID-19.

Data Sources: PubMed and Embase databases were systematically searched from December 31, 2019, until September 1, 2020.

Study Selection: The meta-analysis included any study design, with the exception of narrative reviews or opinion-based articles, in which COVID-19 was diagnosed through laboratory or radiological test results and in which clinical outcomes (unadjusted or adjusted) associated with COVID-19 were assessed among adult patients (≥18 years) receiving ACEIs or ARBs.

Data Extraction And Synthesis: Three authors independently extracted data on mortality and severe AEs associated with COVID-19. Severe AEs were defined as intensive care unit admission or the need for assisted ventilation. For each outcome, a random-effects model was used to compare the odds ratio (OR) between patients receiving ACEIs or ARBs vs those not receiving ACEIs or ARBs.

Main Outcomes And Measures: Unadjusted and adjusted ORs for mortality and severe AEs associated with COVID-19.

Results: A total of 1788 records from the PubMed and Embase databases were identified; after removal of duplicates, 1664 records were screened, and 71 articles underwent full-text evaluation. Clinical data were pooled from 52 eligible studies (40 cohort studies, 6 case series, 4 case-control studies, 1 randomized clinical trial, and 1 cross-sectional study) enrolling 101 949 total patients, of whom 26 545 (26.0%) were receiving ACEIs or ARBs. When adjusted for covariates, significant reductions in the risk of death (adjusted OR [aOR], 0.57; 95% CI, 0.43-0.76; P < .001) and severe AEs (aOR, 0.68; 95% CI, 0.53-0.88; P < .001) were found. Unadjusted and adjusted analyses of a subgroup of patients with hypertension indicated decreases in the risk of death (unadjusted OR, 0.66 [95% CI, 0.49-0.91]; P = .01; aOR, 0.51 [95% CI, 0.32-0.84]; P = .008) and severe AEs (unadjusted OR, 0.70 [95% CI, 0.54-0.91]; P = .007; aOR, 0.55 [95% CI, 0.36-0.85]; P = .007).

Conclusions And Relevance: In this systematic review and meta-analysis, receipt of ACEIs or ARBs was not associated with a higher risk of multivariable-adjusted mortality and severe AEs among patients with COVID-19 who had either hypertension or multiple comorbidities, supporting the recommendations of medical societies. On the contrary, ACEIs and ARBs may be associated with protective benefits, particularly among patients with hypertension. Future randomized clinical trials are warranted to establish causality.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.3594DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013817PMC
March 2021

Cytoreductive or debulking surgery in ovarian cancer: The name does matter!

J Surg Oncol 2021 May 22;123(8):1846-1847. Epub 2021 Mar 22.

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, India.

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http://dx.doi.org/10.1002/jso.26432DOI Listing
May 2021

Myocardial T1-mapping and extracellular volume in pulmonary arterial hypertension: A systematic review and meta-analysis.

Magn Reson Imaging 2021 06 18;79:66-75. Epub 2021 Mar 18.

Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK; Department of Clinical Radiology, Sheffield Teaching Hospitals, Sheffield, UK; Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.

Introduction: Elevated myocardial T-mapping and extracellular volume (ECV) measured on cardiac MR (CMR) imaging is associated with myocardial abnormalities such as oedema or fibrosis. This meta-analysis aims to provide a summary of T-mapping and ECV values in pulmonary arterial hypertension (PAH) and compare their values with controls.

Methods: We searched CENTRAL, MEDLINE, Embase, and Web of Science in August 2020. We included CMR studies reporting T-mapping or ECV values in adults with any type of PAH. We calculated the mean difference of T-values and ECV between PAH and controls.

Results: We included 12 studies with 674 participants. T-values were significantly higher in PAH with the highest mean difference (MD) recorded at the RV insertion points (RVIP) (108 milliseconds (ms), 95% confidence intervals (CI) 89 to 128), followed by the RV free wall (MD 91 ms, 95% CI 56 to 126). The pooled mean T-value in PAH at the RVIP was 1084, 95% CI (1071 to 1097) measured using 1.5 Tesla Siemens systems. ECV was also higher in PAH with an MD of 7.5%, 95% CI (5.9 to 9.1) at the RV free wall.

Conclusion: T mapping values in PAH patients are on average 9% higher than healthy controls when assessed under the same conditions including the same MRI system, magnetic field strength or sequence used for acquisition. The highest T and ECV values are at the RVIP. T mapping and ECV values in PH are higher than the values reported in cardiomyopathies and were associated with poor RV function and RV dilatation.
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http://dx.doi.org/10.1016/j.mri.2021.03.011DOI Listing
June 2021

The strength of a randomized controlled trial lies in its design-randomization.

Support Care Cancer 2021 Mar 19. Epub 2021 Mar 19.

Department of Surgical Oncology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India.

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http://dx.doi.org/10.1007/s00520-021-06163-3DOI Listing
March 2021