Publications by authors named "Siddharth Jain"

80 Publications

Fibromyalgia influences health-related quality of life and disease activity in psoriatic arthritis.

Rheumatol Int 2021 Jul 12. Epub 2021 Jul 12.

Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Fibromyalgia syndrome (FMS) is common in patients of psoriatic arthritis (PsA), but the magnitude of its impact is uncertain. This cross-sectional study evaluated the impact of FMS on health-related quality of life (HRQoL) and disease activity in PsA. Adults classified with PsA (CASPAR criteria) at the rheumatology and dermatology outpatient clinics of PGIMER, Chandigarh, India between January 2014 and June 2015 were recruited. All patients were assessed for FMS using the 2010 ACR criteria. Health-related quality of life was assessed using PROMIS-HAQ, HAQ-pain, HAQ-health and revised fibromyalgia impact questionnaire (FIQR). Disease activity measures (SJC, TJC, BASDAI, enthesitis, dactylitis, PASI) and PROMIS-HAQ were correlated with measures of FMS [FIQR, symptom severity scale (SSS) score and widespread pain index (WPI)]. Multivariate regression analyses were used to identify predictors of PROMIS-HAQ and FMS. Out of 106 PsA patients screened, 102 [50 (49%) females; mean age 43.8 (12.4) years] were included. 19 (18.3%) had FMS. Patients of PsA with FMS had significantly (p < 0.05) higher TJC (14 vs 7), SJC (10 vs 5), BASDAI (6.1 vs 4.1) and enthesitis (53 vs 33%), but no difference in dactylitis, severity of skin disease and disease duration. A significant positive correlation of measures of FMS (FIQR, SSS and WPI) with SJC, TJC and BASDAI was noted. PROMIS-HAQ, HAQ-pain and HAQ-health were significantly worse (p < 0.001) in patients of PsA with coexisting FMS. Presence of FMS was found to be an independent predictor of worse PROMIS-HAQ. Female gender and higher TJC independently predicted presence of FMS. To conclude, FMS is an important contributor towards poor HRQoL in patients of PsA and is associated with higher values of joint disease activity measures.
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http://dx.doi.org/10.1007/s00296-021-04925-0DOI Listing
July 2021

Correspondence on 'Five-year treat-to-target outcomes after methotrexate induction therapy with or without other csDMARDs and temporary glucocorticoids for rheumatoid arthritis in the CareRA trial'.

Ann Rheum Dis 2021 Jun 30. Epub 2021 Jun 30.

Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India

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http://dx.doi.org/10.1136/annrheumdis-2021-220816DOI Listing
June 2021

A Case Report of Chondromyxoid Fibroma of the Neck of Femur, Intracapsular Location.

J Orthop Case Rep 2021 ;11(1):79-81

Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Chondromyxoid fibroma (CMF) is an uncommon benign tumor accounts for <2% of all benign and <1% all bone tumors. It is a cartilage tumor with myxoid and fibrous elements. Because of rarity and resemblance with other benign and malignant tumor, diagnosis of this tumor always remains challenging. Often, this lesion affects metaphysis of long growing bones of children and young adults. Common locations of this tumor are around the growth plate of proximal tibia and fibula and distal femur.

Case Report: A 21-year-old male presented to orthopedic outpatient department with a history of the left hip pain for 1 year, following a trivial fall before 1 year. The patient was not able to do heavy strenuous activities such as running, jumping, and other sports activities. Terminal range of movements were painful. Magnetic resonance imaging suggested of cystic lesion involving synovial lining near head-and-neck junction of the left femur. Curettage of the lesion was done. The bone defect was not found to be large enough to be filled with bone graft. Histopathological examination showed lobular pattern with stellate to spindle-shaped cells on the myxoid background.

Conclusion: CMF of subcapital region of femoral neck is an extremely unusual presentation. When occurring in middle-aged persons and in uncommon locations, this can raise suspicion of chondrosarcoma. Although intralesional curettage has the risk of recurrence in post-operative period, sufficient and careful curettage and excision of lesion will be enough to treat these benign lesions with good prognosis.
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http://dx.doi.org/10.13107/jocr.2021.v11.i01.1972DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046461PMC
January 2021

Musculoskeletal Urgent Care Centers Restrict Access for Patients with Medicaid Insurance Based on Policy and Location.

Clin Orthop Relat Res 2021 06 11. Epub 2021 Jun 11.

D. Wiznia, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA.

Background: As the urgent care landscape evolves, specialized musculoskeletal urgent care centers (MUCCs) are becoming more prevalent. MUCCs have been offered as a convenient, cost-effective option for timely acute orthopaedic care. However, a recent "secret-shopper" study on patient access to MUCCs in Connecticut demonstrated that patients with Medicaid had limited access to these orthopaedic-specific urgent care centers. To investigate how generalizable these regional findings are to the United States, we conducted a nationwide secret-shopper study of MUCCs to identify determinants of patient access.

Questions/purposes: (1) What proportion of MUCCs in the United States provide access for patients with Medicaid insurance? (2) What factors are associated with MUCCs providing access for patients with Medicaid insurance? (3) What barriers exist for patients seeking care at MUCCs?

Methods: An online search of all MUCCs across the United States was conducted in this cross-sectional study. Three separate search modalities were used to gather a complete list. Of the 565 identified, 558 were contacted by phone with investigators posing over the telephone as simulated patients seeking treatment for a sprained ankle. Thirty-nine percent (216 of 558) of centers were located in the South, 13% (71 of 558) in the West, 25% (138 of 558) in the Midwest, and 24% (133 of 558) in New England. This study was given an exemption waiver by our institution's IRB. MUCCs were contacted using a standardized script to assess acceptance of Medicaid insurance and identify barriers to care. Question 1 was answered through determining the percentage of MUCCs that accepted Medicaid insurance. Question 2 considered whether there was an association between Medicaid acceptance and factors such as Medicaid physician reimbursements or MUCC center type. Question 3 sought to characterize the prevalence of any other means of limiting access for Medicaid patients, including requiring a referral for a visit and disallowing continuity of care at that MUCC.

Results: Of the MUCCs contacted, 58% (323 of 558) accepted Medicaid insurance. In 16 states, the proportion of MUCCs that accepted Medicaid was equal to or less than 50%. In 22 states, all MUCCs surveyed accepted Medicaid insurance. Academic-affiliated MUCCs accepted Medicaid patients at a higher proportion than centers owned by private practices (odds ratio 14 [95% CI 4.2 to 44]; p < 0.001). States with higher Medicaid physician reimbursements saw proportional increases in the percentage of MUCCs that accepted Medicaid insurance under multivariable analysis (OR 36 [95% CI 14 to 99]; p < 0.001). Barriers to care for Medicaid patients characterized included location restriction and primary care physician referral requirements.

Conclusion: It is clear that musculoskeletal urgent care at these centers is inaccessible to a large segment of the Medicaid-insured population. This inaccessibility seems to be related to state Medicaid physician fee schedules and a center's affiliation with a private orthopaedic practice, indicating how underlying financial pressures influence private practice policies. Ultimately, the refusal of Medicaid by MUCCs may lead to disparities in which patients with private insurance are cared for at MUCCs, while those with Medicaid may experience delays in care. Going forward, there are three main options to tackle this issue: increasing Medicaid physician reimbursement to provide a financial incentive, establishing stricter standards for MUCCs to operate at the state level, or streamlining administration to reduce costs overall. Further research will be necessary to evaluate which policy intervention will be most effective.

Level Of Evidence: Level II, prognostic study.
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http://dx.doi.org/10.1097/CORR.0000000000001825DOI Listing
June 2021

Comparison of two dose escalation strategies of methotrexate in active rheumatoid arthritis: a multicentre, parallel group, randomised controlled trial.

Ann Rheum Dis 2021 Jun 10. Epub 2021 Jun 10.

Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Objectives: There are no head-to-head trials of different dose escalation strategies of methotrexate (MTX) in RA. We compared the efficacy, safety and tolerability of 'usual' (5 mg every 4 weeks) versus 'fast' (5 mg every 2 weeks) escalation of oral MTX.

Methods: This multicentre, open-label (assessor blinded) RCT included patients 18-55 years of age having active RA with disease duration <5 years, and not on DMARDs. Patients were randomized 1:1 into usual or fast escalation groups, both groups starting MTX at 15 mg/week till a maximum of 25 mg/week. Primary outcome was EULAR good response at 16 weeks, secondary outcomes were ΔDAS28 and adverse effects (AE). Analyses were intention-to-treat.

Results: 178 patients with mean DAS28-CRP of 5.4(1.1) were randomized to usual (n=89) or fast escalation groups (n=89). At 16 weeks, there was no difference in good EULAR response in the usual (28.1%) or fast escalation (22.5%) groups (p=0.8). There was no difference in mean ΔDAS28-CRP at 8 weeks (-0.9, -0.8, p=0.72) or 16 weeks (-1.3, -1.3, p=0.98). Even at 24 weeks (extended follow-up), responses were similar. There were no inter-group differences in ΔHAQ, or MTX-polyglutamates 1-3 levels at 8 or 16 weeks. Gastrointestinal AE were higher in the fast escalation group over initial 8 weeks (27%, 40%, p=0.048), but not over 16 weeks. There was no difference in cytopenias, transaminitis, or drug discontinuation/dose reduction between the groups. No serious AE were seen.

Conclusion: A faster MTX escalation strategy in RA was not more efficacious over 16-24 weeks, and did not significantly increase AE, except higher gastrointestinal AE initially.

Trial Registration Number: CTRI/2018/12/016549.
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http://dx.doi.org/10.1136/annrheumdis-2021-220512DOI Listing
June 2021

Habitual Patellar Dislocation-Management by Two in One Procedure, Short Term Results.

Indian J Orthop 2021 Apr 27;55(2):392-396. Epub 2020 Apr 27.

Indian Army Classified Specialist Orthopaedics, New Delhi, India.

Aim: Habitual dislocation of patella is an uncommon pathological condition. Though numerous techniques have been described in the literature for the treatment of patellar dislocations, none of the single procedure is fully effective in the surgical treatment of habitual dislocation of patella. We described our experience with a two in one procedure for habitual dislocation of patella in ten children.

Patients And Method: Ten children having habitual dislocation were reviewed prospectively for twelve months following surgical procedure. The age ranged between 5 and 9 years. We performed graded lateral soft tissue release and patellar tendon transposition as described by Roux Goldthwait. Clinical results were evaluated using Kujala score, ability to do straight leg raise, knee range of motion and visual analogue scale.

Result: There has been no recurrence of dislocation. The mean Kujala score before surgery was 48 which improved to 97.8 at 12 months follow-up after the surgical procedure. At 12 months follow-up all patients were able to do straight leg raise and had almost full range of motion.

Conclusion: We conclude that extensive proximal lateral release along with Goldthwait Roux procedure helps in treating the habitual dislocation in patella in children. Decision for the extent of lateral release must be taken intra-operatively. Our method of treatment is simple, cost effective and reproducible with excellent functional outcome.
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http://dx.doi.org/10.1007/s43465-020-00114-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046870PMC
April 2021

Urgent care center wait times increase for COVID-19 results in August 2020, with rapid testing availability limited.

BMC Health Serv Res 2021 Apr 8;21(1):318. Epub 2021 Apr 8.

Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, 800 Howard Avenue, New Haven, Connecticut, 06520, USA.

Background: In a response to the pandemic, urgent care centers (UCCs) have gained a critical role as a common location for COVID-19 testing. We sought to characterize the changes in testing accessibility at UCCs between March and August 2020 on the basis of testing availability (including rapid antigen testing), wait time for test results, cost of visits, and cost of tests.

Methods: Data were collected using a secret shopper methodology. Researchers contacted 250 UCCs in 10 states. Investigators used a standardized script to survey centers on their COVID-19 testing availability and policies. UCCs were initially contacted in March and re-called in August. T-tests and chi-square tests were conducted to identify differences between March and August data and differences by center classification.

Results: Our results indicate that both polymerase chain reaction (PCR) tests to detect COVID-19 genetic material and rapid antigen COVID-19 tests have increased in availability. However, wait times for PCR test results have significantly increased to an average of 5.79 days. Additionally, a high proportion of UCCs continue to charge for tests and visits and no significant decrease was found in the proportion of UCCs that charge for COVID-19 testing from March to August. Further, no state reported a majority of UCCs with rapid testing available, indicating an overall lack of rapid testing.

Conclusions: From March to August, COVID-19 testing availability gradually improved. However, many barriers lie in access to COVID-19 testing, including testing costs, visit costs, and overall lack of availability of rapid testing in the majority of UCCs. Despite the passage of the CARES Act, these results suggest that there is room for additional policy to improve accessibility to testing, specifically rapid testing.
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http://dx.doi.org/10.1186/s12913-021-06338-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8027963PMC
April 2021

Efficacy and safety of hydroxychloroquine/chloroquine against SARS-CoV-2 infection: A systematic review and meta-analysis.

J Infect Chemother 2021 Jun 22;27(6):882-889. Epub 2021 Feb 22.

Department of Radiodiagnosis, Government Medical College and Hospital -32, Chandigarh, India. Electronic address:

Introduction: Hydroxychloroquine (HCQ)/Chloroquine (CQ) has been evaluated for treatment and prophylaxis against SARS-CoV-2 infection in various studies with conflicting results. We performed a systematic review to synthesize the currently available evidence over the efficacy and safety of HCQ/CQ therapy alone against SARS-CoV-2 infection.

Methods: We searched Embase, PubMed, Web of Science, and Cochrane central for randomized controlled trials (RCTs) and prospective cohort studies published until October 15, 2020 and assessing the efficacy of HCQ alone against SARS-CoV-2 infection. We included studies evaluating HCQ/CQ alone as intervention and placebo/standard care as a control group. Retrospective studies and studies using other drugs (namely azithromycin, corticosteroids, immunomodulators, etc.) we excluded. Thirteen RCTs and three prospective cohort studies were included in this review. We pooled data using a random-effect model.

Results: Pooled data from 12 studies (9917 participants) showed that HCQs increase mortality as compared to placebo/standard of care (RR 1.10; 95% CI:1.00-1.20). Hydroxychloroquine did not reduce the need for hospitalization in out-patients (RR 0.57; 95% CI 0.31-1.02). HCQ group has a significantly higher rate of any adverse event (RR 2.68; 95% CI 1.55-4.64), as compared to the control group. Also, using HCQ for prophylaxis against SARS-CoV-2 infection did not reduce the risk of acquiring SARS-CoV-2 infection (RR 1.04; 95% CI 0.58-1.88).

Conclusions: HCQ therapy for COVID-19 is associated with an increase in mortality and other adverse events. The negative effects are more pronounced in hospitalized patients. Therefore, with the available evidence, HCQ should not be used in prophylaxis or treatment of patients with COVID-19.
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http://dx.doi.org/10.1016/j.jiac.2021.02.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899036PMC
June 2021

Bilateral gluteus maximus contracture due to intra muscular injections.

Trop Doct 2021 Jan 10:49475520984747. Epub 2021 Jan 10.

Fellow in Arthroscopy, Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India.

Gluteus maximus contracture, characterised by contracture of gluteus maximus, iliotibial band and covering fascia, can be caused by repeated intramuscular injections in the gluteal region. It is amenable to open surgical release.
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http://dx.doi.org/10.1177/0049475520984747DOI Listing
January 2021

COVID-19 testing capabilities at urgent care centers in states with greatest disease burden.

F1000Res 2020;9:328. Epub 2020 May 4.

Department of Orthopaedics, Yale School of Medicine, New Haven, CT, 06511, USA.

While rapid and accessible diagnosis is paramount to monitoring and reducing the spread of disease, COVID-19 testing capabilities across the U.S. remain constrained. For many individuals, urgent care centers (UCCs) may offer the most accessible avenue to be tested. Through a phone survey, we describe the COVID-19 testing capabilities at UCCs and provide a snapshot highlighting the limited COVID-19 testing capabilities at UCCs in states with the greatest disease burden.
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http://dx.doi.org/10.12688/f1000research.23203.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7689602PMC
January 2021

Clinical Profile and Outcome of COVID-19 in 250 Kidney Transplant Recipients: A Multicenter Cohort Study From India.

Transplantation 2021 04;105(4):851-860

IKDRC-ITS, Ahmedabad, Gujarat, India.

Background: There is a scarcity of data on the consequences of coronavirus disease-19 (COVID-19) infections in kidney transplant recipients (KTRs) from emerging countries.

Methods: Here, we present a cohort study of 13 transplant centers in India including 250 KTR (226 living and 24 deceased donors) with polymerase chain reaction-confirmed COVID-19 positivity from March 23, 2020, until September 15, 2020. We detailed demographics, immunosuppression regimen, clinical profile, treatment, and outcomes.

Results: Median age of transplant recipients was 43 years, and recipients presented at a median of 3.5 years after transplant. Most common comorbidities (94%) included arterial hypertension (84%) and diabetes (32%); presenting symptoms at the time of COVID-19 included fever (88%), cough (72%), and sputum production (52%). Clinical severity ranged from asymptomatic (6%), mild (60%), and moderate (20%) to severe (14%). Strategies to modify immunosuppressants included discontinuation of antimetabolites without changes in calcineurin inhibitors and steroids (60%). Risk factors for mortality included older age; dyspnea; severe disease; obesity; allograft dysfunction before COVID-19 infection; acute kidney injury; higher levels of inflammatory markers including C-reactive protein, interleukin-6 level, and procalcitonin; chest X-ray abnormality, and intensive care unit/ventilator requirements. Overall patient mortality was 11.6% (29 of 250), 14.5% (29 of 200) in hospitalized patients, 47% (25 of 53) in intensive care unit patients, and 96.7% (29 of 30) in patients requiring ventilation. KTRs with mild COVID-19 symptoms (n = 50) were managed as outpatients to optimize the utilization of scarce resources during the COVID-19 pandemic.

Conclusions: Mortality rates in COVID-19-positive KTR appear to be higher than those in nonimmunosuppressed patients, and high mortality was noted among those requiring intensive care and those on ventilator.
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http://dx.doi.org/10.1097/TP.0000000000003593DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7993652PMC
April 2021

Long-Term Rituximab Use to Maintain Remission of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis.

Ann Intern Med 2020 12;173(11):947

Postgraduate Institute of Medical Education and Research, Chandigarh, India (S.J., A.C., A.S.).

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http://dx.doi.org/10.7326/L20-1197DOI Listing
December 2020

Alzheimer's Dementia After Exposure to Anesthesia and Surgery in the Elderly: A Matched Natural Experiment Using Appendicitis.

Ann Surg 2020 Nov 17. Epub 2020 Nov 17.

Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

Objective: To determine if surgery and anesthesia in the elderly may promote Alzheimer's Disease and Related Dementias (ADRD).

Background: There is a substantial conflicting literature concerning the hypothesis that surgery and anesthesia promotes ADRD. Much of the literature is confounded by indications for surgery or has small sample size. This study examines elderly patients with appendicitis, a common condition that strikes mostly at random after controlling for some known associations.

Methods: A matched natural experiment of patients undergoing appendectomy for appendicitis versus control patients without appendicitis using Medicare data from 2002 to 2017, examining 54,996 patients without previous diagnoses of ADRD, cognitive impairment, or neurological degeneration, who developed appendicitis between ages 68 through 77 years and underwent an appendectomy (the "Appendectomy" treated group), matching them 5:1 to 274,980 controls, examining the subsequent hazard for developing ADRD.

Results: The hazard ratio (HR) for developing ADRD or death was lower in the Appendectomy group than controls: HR = 0.96 (95% CI 0.94, 0.98), P < 0.0001, (28.2% in Appendectomy versus 29.1% in controls, at 7.5 years). The HR for death was 0.97 (0.95, 0.99), P = 0.002, (22.7% versus 23.1% at 7.5 years). The HR for developing ADRD alone was 0.89 (0.86, 0.92), P < 0.0001, (7.6% in Appendectomy versus 8.6% in controls, at 7.5 years). No subgroup analyses found significantly elevated rates of ADRD in the Appendectomy group.

Conclusions: In this natural experiment involving 329,976 elderly patients, exposure to appendectomy surgery and anesthesia did not increase the subsequent rate of ADRD.
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http://dx.doi.org/10.1097/SLA.0000000000004632DOI Listing
November 2020

Using Medicare claims in identifying Alzheimer's disease and related dementias.

Alzheimers Dement 2020 Oct 8. Epub 2020 Oct 8.

Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Introduction: This study develops a measure of Alzheimer's disease and related dementias (ADRD) using Medicare claims.

Methods: Validation resembles the approach of the American Psychological Association, including (1) content validity, (2) construct validity, and (3) predictive validity.

Results: We found that four items-a Medicare claim recording ADRD 1 year ago, 2 years ago, 3 years ago, and a total stay of 6 months in a nursing home-exhibit a pattern of association consistent with a single underlying ADRD construct, and presence of any two of these four items predict a direct measure of cognitive function and also future claims for ADRD.

Discussion: Our four items are internally consistent with the measurement of a single quantity. The presence of any two items do a better job than a single claim when predicting both a direct measure of cognitive function and future ADRD claims.
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http://dx.doi.org/10.1002/alz.12199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8296851PMC
October 2020

Tocilizumab in COVID-19: finding the optimal route and dose.

Lancet Rheumatol 2020 Dec 17;2(12):e738-e739. Epub 2020 Sep 17.

Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.

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http://dx.doi.org/10.1016/S2665-9913(20)30334-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7498201PMC
December 2020

Urgent Care Centers Delay Emergent Surgical Care Based on Patient Insurance Status in The United States.

Ann Surg 2020 10;272(4):548-553

Department of Surgery, Division of General Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, CT.

Objective: Patients may call urgent care centers (UCCs) with urgent surgical conditions but may not be properly referred to a higher level of care. This study aims to characterize how UCCs manage Medicaid and privately insured patients who present with an emergent condition.

Methods: Using a standardized script, we called 1245 randomly selected UCCs in 50 states on 2 occasions. Investigators posed as either a Medicaid or a privately-insured patient with symptoms of an incarcerated inguinal hernia. Rates of direct emergency department (ED) referral were compared between insurance types.

Results: A total of 1223 (98.2%) UCCs accepted private insurance and 981 (78.8%) accepted Medicaid. At the 971 (78.0%) UCCs that accepted both insurance types, direct-to-ED referral rates for private and Medicaid patients were 27.9% and 33.8%, respectively. Medicaid patients were significantly more likely than private patients to be referred to the ED [odds ratio (OR) 1.32, 95% confidence interval (CI) 1.09-1.60]. Private patients who were triaged by a clinician compared to nonclinician staff were over 6 times more likely to be referred to the ED (OR 6.46, 95% CI 4.63-9.01). Medicaid patients were nearly 9 times more likely to have an ED referral when triaged by a clinician (OR 8.72, 95% CI 6.19-12.29).

Conclusions: Only one-third of UCCs across the United States referred an apparent emergent surgical case to the ED, potentially delaying care. Medicaid patients were more likely to be referred directly to the ED versus privately insured patients. All patients triaged by clinicians were significantly more likely to be referred to the ED; however, the disparity between private and Medicaid patients remained.
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http://dx.doi.org/10.1097/SLA.0000000000004373DOI Listing
October 2020

Evaluating the Costs and Outcomes of Hospital Nursing Resources: a Matched Cohort Study of Patients with Common Medical Conditions.

J Gen Intern Med 2021 01 31;36(1):84-91. Epub 2020 Aug 31.

Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.

Background: Nursing resources, such as staffing ratios and skill mix, vary across hospitals. Better nursing resources have been linked to better patient outcomes but are assumed to increase costs. The value of investments in nursing resources, in terms of clinical benefits relative to costs, is unclear.

Objective: To determine whether there are differential clinical outcomes, costs, and value among medical patients at hospitals characterized by better or worse nursing resources.

Design: Matched cohort study of patients in 306 acute care hospitals.

Patients: A total of 74,045 matched pairs of fee-for-service Medicare beneficiaries admitted for common medical conditions (25,446 sepsis pairs; 16,332 congestive heart failure pairs; 12,811 pneumonia pairs; 10,598 stroke pairs; 8858 acute myocardial infarction pairs). Patients were also matched on hospital size, technology, and teaching status.

Main Measures: Better (n = 76) and worse (n = 230) nursing resourced hospitals were defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses, and nurse work environments. Outcomes included 30-day mortality, readmission, and resource utilization-based costs.

Key Results: Patients in hospitals with better nursing resources had significantly lower 30-day mortality (16.1% vs 17.1%, p < 0.0001) and fewer readmissions (32.3% vs 33.6%, p < 0.0001) yet costs were not significantly different ($18,848 vs 18,671, p = 0.133). The greatest outcomes and cost advantage of better nursing resourced hospitals were in patients with sepsis who had lower mortality (25.3% vs 27.6%, p < 0.0001). Overall, patients with the highest risk of mortality on admission experienced the greatest reductions in mortality and readmission from better nursing at no difference in cost.

Conclusions: Medicare beneficiaries with common medical conditions admitted to hospitals with better nursing resources experienced more favorable outcomes at almost no difference in cost.
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http://dx.doi.org/10.1007/s11606-020-06151-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458128PMC
January 2021

WU-NEAT: A clinically validated, open-source MATLAB toolbox for limited-channel neonatal EEG analysis.

Comput Methods Programs Biomed 2020 Nov 20;196:105716. Epub 2020 Aug 20.

Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, USA.

Background: Limited-channel EEG research in neonates is hindered by lack of open, accessible analytic tools. To overcome this limitation, we have created the Washington University-Neonatal EEG Analysis Toolbox (WU-NEAT), containing two of the most commonly used tools, provided in an open-source, clinically-validated package running within MATLAB.

Methods: The first algorithm is the amplitude-integrated EEG (aEEG), which is generated by filtering, rectifying and time-compressing the original EEG recording, with subsequent semi-logarithmic display. The second algorithm is the spectral edge frequency (SEF), calculated as the critical frequency below which a user-defined proportion of the EEG spectral power is located. The aEEG algorithm was validated by three experienced reviewers. Reviewers evaluated aEEG recordings of fourteen preterm/term infants, displayed twice in random order, once using a reference algorithm and again using the WU-NEAT aEEG algorithm. Using standard methodology, reviewers assigned a background pattern classification. Inter/intra-rater reliability was assessed. For the SEF, calculations were made using the same fourteen recordings, first with the reference and then with the WU-NEAT algorithm. Results were compared using Pearson's correlation coefficient.

Results: For the aEEG algorithm, intra- and inter-rater reliability was 100% and 98%, respectively. For the SEF, the mean±SD Pearson correlation coefficient between algorithms was 0.96±0.04.

Conclusion: We have demonstrated a clinically-validated toolbox for generating the aEEG as well as calculating the SEF from EEG data. Open-source access will enable widespread use of common analytic algorithms which are device-independent and unlikely to become outdated as technology changes, thereby facilitating future collaborative research in neonatal EEG.
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http://dx.doi.org/10.1016/j.cmpb.2020.105716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7606381PMC
November 2020

Ovarian dysfunction with moderate-dose intravenous cyclophosphamide (modified NIH regimen) and mycophenolate mofetil in young adults with severe lupus: a prospective cohort study.

Arthritis Res Ther 2020 08 14;22(1):189. Epub 2020 Aug 14.

Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background: Ovarian toxicity is a dreaded complication of cyclophosphamide (CYC). With the use of lower cumulative doses of intravenous CYC (modified NIH regimens) and availability of better markers of ovarian toxicity, the incidence of ovarian dysfunction needs reassessment. Lupus disease activity, by itself, is also believed to affect ovarian function negatively.

Methods: This single-centre prospective cohort study recruited 50 female patients of severe lupus aged 18-40 years. Twenty-five patients each received induction with either monthly intravenous CYC (0.5-0.75 g/m) for 6-9 months or daily oral mycophenolate mofetil (MMF). Details of menstrual irregularities; serum levels of FSH, LH, estradiol, AMH, and inhibin B; and sonographic assessment of ovarian volume and antral follicular count were done at baseline and 6 months after treatment. Amenorrhoeic patients were re-evaluated at 1 year.

Results: Mean (SD) age of subjects in the CYC and MMF groups was 31.4 (6.3) and 28.4 (4.4) years, respectively. Mean (SD) SLEDAI at the initiation of therapy was 7.2 (2.5) in the CYC group and 5.8 (3.4) in the MMF group. The mean cumulative dose of CYC used was 4.6 (1.8) g. Three patients in the CYC group (versus none in MMF) had amenorrhoea at 6 months-two of these regained menses within 6 months, while only one (4%) developed sustained amenorrhoea (lasting more than 12 months) at 41 years of age, likely menopause. Serum FSH levels increased (p = 0.03), while AMH (p = 0.002) and inhibin B (p < 0.001) levels decreased significantly with 6 months of CYC therapy. Ovarian volume also reduced significantly (p = 0.005) with 6 months of CYC therapy, while antral follicular count reduced numerically (p = 0.32). Levels of AMH, inhibin-B, estradiol, ovarian volume, and antral follicular count after 6 months therapy were significantly lesser in the CYC group compared to the MMF group, despite being similar before the start of therapy.

Conclusions: Ovarian dysfunction with monthly intravenous CYC (modified NIH regimen) was predominantly subclinical, with a negative effect on ovarian reserve. No premature ovarian failure was noted at 1 year. No ovarian dysfunction occurred in the MMF group, despite having patients with severe background lupus. Use of intravenous CYC for induction may thus not be restricted in young lupus females with incomplete families for fear of gonadotoxicity, especially in life- or organ-threatening situations, where the benefits outweigh this subclinical risk.
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http://dx.doi.org/10.1186/s13075-020-02292-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429750PMC
August 2020

Robotic Excision of Upper Ureteral Fibroepithelial Polyp Presenting as Pelviureteral Junction Obstruction: Surgical Surprise with Review of Literature.

J Endourol Case Rep 2020 11;6(1):30-34. Epub 2020 Mar 11.

Department of Urology, All India Institute of Medical Sciences, New Delhi, India.

Fibroepithelial polyps in the upper ureter are a rare cause of pelviureteral junction obstruction (PUJO). Its diagnosis usually remains challenging by clinical and radiologic means. We discuss a case of 19-year-old boy who present with intermittent left flank pain. Radiologic imaging suggested diagnosis of PUJO. We planned for robotic pyeloplasty. Intraoperatively pelviureteral junction (PUJ) was dependent, nonstenotic with upper hydroureteronephrosis creating suspicion of polyp. Keeping suspicion of polyp in upper ureter, we did robotic upper ureterotomy. This procedure revealed a 1 × 1 cm benign polyp at PUJ, which was excised completely. Polyps in the upper ureter constitute uncommon clinical cause of PUJO and usually diagnosed intraoperatively. Robotic approach is a feasible, acceptable, and safe option in such clinical scenario. It provides all the benefits of minimal invasive surgical procedures.
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http://dx.doi.org/10.1089/cren.2019.0088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383437PMC
March 2020

A Case of Type 1 Papillary Renal Cell Cancer with Pelvic Tumor Thrombus Masquerading as Urothelial Cancer with Review of Literature.

J Endourol Case Rep 2019 2;5(4):157-160. Epub 2019 Dec 2.

Department of Urology, All India Institute of Medical Sciences, New Delhi, India.

Adult renal tumors vary from renal cell carcinoma (RCC) to upper tract urothelial cancer (UTUC). Tumor characteristics such as renal vein and inferior vena cava tumor thrombus are usually seen with RCC, but tumor thrombus into pelvicaliceal system (PCS) is a rare entity in RCC. At present only 11 cases have been reported in the literature. We report an unusual case of papillary type 1 RCC in a young Muslim man mimicking as UTUC radiologically and found to have free tumor thrombus in PCS. At follow-up of 6 months after right nephroureterectomy with bladder cuff excision, he is doing well clinically and radiologically without any recurrence. RCC with tumor thrombus into PCS is an uncommon entity. It can give similar appearance as an urothelial cancer of the pelvis on radiologic imaging. Pelvic tumor thrombus is now considered as a factor of poor prognostic importance and rarely encountered with pure papillary type of RCC.
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http://dx.doi.org/10.1089/cren.2019.0056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383424PMC
December 2019

Determinants of Morning Stiffness in Rheumatoid Arthritis: Comment on the Article by Orange et al.

Arthritis Rheumatol 2021 01 7;73(1):174-175. Epub 2020 Dec 7.

Postgraduate Institute of Medical Education and Research, Chandigarh, India.

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http://dx.doi.org/10.1002/art.41459DOI Listing
January 2021

Rational use of tocilizumab in COVID-19.

Ann Rheum Dis 2020 Jul 31. Epub 2020 Jul 31.

Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India

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http://dx.doi.org/10.1136/annrheumdis-2020-218519DOI Listing
July 2020

Experimental Study on Biodiesel Production Parameter Optimization of Jatropha-Algae Oil Mixtures and Performance and Emission Analysis of a Diesel Engine Coupled with a Generator Fueled with Diesel/Biodiesel Blends.

ACS Omega 2020 Jul 6;5(28):17033-17041. Epub 2020 Jul 6.

Department of Mechanical Engineering, U. I. E. T., Chandigarh 160014, India.

Methyl ester production from jatropha-algae oil is conducted through a transesterification process. Consequences of four parameters, the molar ratio (oil:methanol), the reaction temperature, the amount of catalyst, and the reaction time for obtaining a higher yield of biodiesel, are derived, and the process was optimized using the response surface methodology based on the Box-Behnken Design. An optimized biodiesel yield of 96% is achieved at a molar ratio of 1:10, a reaction temperature of 53° C, a 0.3 wt% catalyst, and a reaction time of 172 min. The predicted optimal conditions were experimentally validated with a relative error of 4% of the experimental result (96%). The value of ANOVA is <0.0001, which shows that the model is significant. Finally, the performance and emissions in a diesel engine coupled with an electricity generator powered by biodiesel blends (B0, B5, B10, and B20% vol.) were investigated, concluding a significant reduction of exhaust gases. The engine was run with numerous blends of biodiesel by changing the brake power from 0 load to 0.5, 1, 1.5, and 2 KW.
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http://dx.doi.org/10.1021/acsomega.9b04372DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7377547PMC
July 2020

Riociguat in systemic sclerosis: a potential for disease modification.

Ann Rheum Dis 2020 Jul 15. Epub 2020 Jul 15.

Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India

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http://dx.doi.org/10.1136/annrheumdis-2020-218180DOI Listing
July 2020

The effect of methotrexate on neutrophil reactive oxygen species and CD177 expression in rheumatoid arthritis.

Clin Exp Rheumatol 2021 May-Jun;39(3):479-486. Epub 2020 Jun 23.

Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Objectives: Neutrophils are found in abundance in the synovial fluid of patients with rheumatoid arthritis (RA), where they are activated and show high reactive oxygen species (ROS) production. However, there is limited data on circulating neutrophils in peripheral blood of patients with RA in terms of ROS production, expression of activation markers and the effect of treatment with methotrexate (MTX) on ROS.

Methods: This single-centre prospective study recruited patients of RA classified as per the 2010 ACR/EULAR criteria. In the cross-sectional arm, we included three groups, treatment-naïve RA (naïve-RA), MTX-treated RA (MTX-RA) and healthy controls, and compared ROS production and surface markers of neutrophil activation. In the longitudinal arm, we studied the change in neutrophil ROS production after 8 weeks of MTX treatment in naïve-RA patients. Neutrophil ROS production was measured by flow cytometry using dihydrorhodamine-123 (DHR) and by chemiluminescence using luminol. Surface expression of CD177, CD11b and CD64 was measured by flow cytometry.

Results: This study included 103 patients (50 naïve-RA, 53 MTX-RA) and 20 controls. Both naïve-RA and MTX-RA patients showed higher ROS production than healthy controls in unstimulated neutrophils in the DHR assay (p<0.001 and p=0.004). MTX-RA patients showed significantly lower ROS production than naive-RA, in both unstimulated (p=0.004) and PMA-stimulated neutrophils in the DHR assay (p=0.03). On longitudinal follow-up of 24 naïve-RA patients, there was a significant reduction of neutrophil ROS production (by 55% from baseline) (p<0.001) after 8 weeks of MTX. Neutrophil CD177 expression was higher in both naïve-RA and MTX-RA (trend) than controls (p=0.001 and p=0.09). MTX-RA neutrophils showed lower expression of CD177 than naïve-RA (p=0.01). CD11b expression was higher in MTX-RA compared to controls (p=0.01).

Conclusions: Circulating neutrophils in RA showed higher ROS production and higher expression of CD177 and CD11b compared to controls. MTX treatment was associated with a reduction in ROS production and CD177 expression, which may be one of the mechanisms by which MTX works in RA.
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May 2021

Valuing hospital investments in nursing: multistate matched-cohort study of surgical patients.

BMJ Qual Saf 2021 01 27;30(1):46-55. Epub 2020 Mar 27.

Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Background: There are known clinical benefits associated with investments in nursing. Less is known about their value.

Aims: To compare surgical patient outcomes and costs in hospitals with better versus worse nursing resources and to determine if value differs across these hospitals for patients with different mortality risks.

Methods: Retrospective matched-cohort design of patient outcomes at hospitals with better versus worse nursing resources, defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses and nurse work environments. The sample included 62 715 pairs of surgical patients in 76 better nursing resourced hospitals and 230 worse nursing resourced hospitals from 2013 to 2015. Patients were exactly matched on principal procedures and their hospital's size category, teaching and technology status, and were closely matched on comorbidities and other risk factors.

Results: Patients in hospitals with better nursing resources had lower 30-day mortality: 2.7% vs 3.1% (p<0.001), lower failure-to-rescue: 5.4% vs 6.2% (p<0.001), lower readmissions: 12.6% vs 13.5% (p<0.001), shorter lengths of stay: 4.70 days vs 4.76 days (p<0.001), more intensive care unit admissions: 17.2% vs 15.4% (p<0.001) and marginally higher nurse-adjusted costs (which account for the costs of better nursing resources): $20 096 vs $19 358 (p<0.001), as compared with patients in worse nursing resourced hospitals. The nurse-adjusted cost associated with a 1% improvement in mortality at better nursing hospitals was $2035. Patients with the highest mortality risk realised the greatest value from nursing resources.

Conclusion: Hospitals with better nursing resources provided better clinical outcomes for surgical patients at a small additional cost. Generally, the sicker the patient, the greater the value at better nursing resourced hospitals.
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http://dx.doi.org/10.1136/bmjqs-2019-010534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7530638PMC
January 2021

Inverse Gottron's sign in anti-MDA5 antibody-associated dermatomyositis.

Rheumatology (Oxford) 2020 Mar 26. Epub 2020 Mar 26.

Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

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http://dx.doi.org/10.1093/rheumatology/keaa108DOI Listing
March 2020

Triple Overlap Between Silicosis, Dermatomyositis, and Systemic Sclerosis: Opening Up a Pandora's Box.

J Clin Rheumatol 2020 Mar 17. Epub 2020 Mar 17.

Rheumatology, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1097/RHU.0000000000001371DOI Listing
March 2020

Arthroscopic Repair of a "U" Shaped Rotator Cuff Tear: Modified Margin Convergence with a Single Triple-loaded Suture Anchor.

Cureus 2020 Jan 17;12(1):e6690. Epub 2020 Jan 17.

Orthopedics, All India Institute of Medical Sciences, New Delhi, IND.

Introduction Repair of a "U" shaped rotator cuff tear tends to create extreme tensile forces at the central part of the rotator cuff margin, causing tensile overload and may result in subsequent failure. We describe our technique of repairing the "U" shaped tear in which margin convergence is done using Ethibond (Ethicon Inc., New Jersey) and a single triple-loaded suture anchor. It results in the reduction of the strain and also allows the repair of seemingly irreparable tears. Patients and method We included 10 patients having a "U" shaped degenerative rotator cuff tear. All patients were assessed preoperatively. The University of California at Los Angeles Shoulder score (UCLA shoulder score) recorded preoperatively and at final follow-up was used to assess functional outcome. Result Out of 10 patients, six were males and four were females. The mean age was 60 years (range 50-70 years). The average follow-up was for 31 months (range 24 - 48 months). The UCLA score increased from an average of 9 preoperatively (range 8 - 12) to an average of 29.6 (range 27 - 31) at the terminal follow-up. The UCLA increased in the postoperative period and was statistically significant (unpaired t-test; p < 0.0001). All patients had good/excellent outcomes (UCLA score > 27). Abduction increased from average 27 degree preoperatively (range 20 degree - 35 degree) to an average 131 degree (range 125 degree - 140 degree) at final follow-up (unpaired t-test; p < 0.0001). Conclusion Our technique of modified margin convergence achieves low tension repair and anatomical footprint reconstruction with good clinical outcomes using a single triple-loaded anchor.
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http://dx.doi.org/10.7759/cureus.6690DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7026873PMC
January 2020