University College of Medical Sciences

Background: Intrahepatic cholestasis of pregnancy (IHCP) is a pregnancy-specific liver disorder associated with adverse fetal outcomes. Elevated maternal serum bile acids (BAs) trigger placental inflammation through the G-protein-coupled bile acid receptor 1 (Gpbar-1) and nuclear factor Kappa-light-chain-enhancer of activated B cells (NF-κB) signaling pathway. This study investigates Gpbar-1 and NF-κB gene expression in placental tissue of IHCP patients and its correlation with fetal outcomes. Methods: This prospective case-control study, conducted between November 2019 and October 2021 at a tertiary care hospital, included 30 diagnosed IHCP cases and 30 gestational age-matched healthy controls. Serum bile acid levels were measured (using Elisa), and placental tissue was analyzed post-delivery using quantitative reverse transcription PCR (RT-qPCR) for Gpbar-1 and NF-κB gene expression. Maternal and fetal outcomes such as preterm delivery, fetal distress, low APGAR score, meconium-stained liquor, and NICU admission were recorded. Results: Serum bile acid levels were significantly higher in IHCP cases (p<0.001). Gene expression analysis showed a 2.192-fold upregulation of Gpbar-1 (p=0.019) and a 2.396 -fold upregulation of NF-κB in IHCP placentas (p=0.029). Adverse fetal outcomes were not significantly correlated with higher gene expression. Conclusions: Elevated bile acid levels in IHCP activate the Gpbar-1/NF-κB pathway, leading to placental inflammation and adverse fetal outcomes. Targeting this pathway may improve pregnancy outcomes in IHCP. Further research on anti-inflammatory therapies is recommended.

Abstract To assess whether omission of non-contrast computed tomography (NCCT) in patients undergoing non-emergent contrast-enhanced CT (CECT) abdomen affects the final CT diagnosis in abdominal diseases. A total of 350 adult patients were selected for non-emergent CECT scan abdomen, and NCCT was omitted. Images were reviewed by two experienced radiologists (R1 and R2) to make primary and secondary CT diagnoses. In case of disagreement, the opinion of a third experienced radiologist (R3) was obtained. The concordance/discordance between the radiologists was calculated. Percentages of cases in which performing CECT alone did not affect the CT diagnosis were calculated. There was concordance between radiologists R1 and R2 for primary CT diagnosis of abdominal diseases in 340/350 patients undergoing non-emergent CECT abdomen, while NCCT was omitted. The secondary CT diagnosis was unaffected by omitting NCCT in 69 out of 70 cases, i.e., 98.57% concordance between R1 and R2. In 10/350 patients (2.86%), omission of NCCT prevented accurate primary CT diagnosis according to R2, while R1 and R3 opined that NCCT was not needed. In all these 10 patients, NCCT findings did not produce any major diagnostic changes. Omission of NCCT prior to non-emergent CECT abdomen does not prevent an accurate diagnosis in a vast majority of abdominal diseases, while reducing the radiation dose by almost half. No previous study is available in which the non-contrast phase has been omitted successfully in adults, before non-emergent CECT, in a large variety of infective and neoplastic abdominal diseases.

IntroductionRevision lumbar spine surgery is an increasing challenge, often necessitated by adjacent segment disease (ASD), recurrent stenosis, or implant-related complications. This study aimed to analyze the etiology and short-term outcomes of revision lumbar surgeries at a tertiary spine center.Materials and methodsA prospective observational study was conducted at our institute, including all revision lumbar surgeries performed during the defined study period. Data collected included patient demographics, details of the index surgery, presenting complaints, indications for revision, characteristics of the revision procedure, and six-month postoperative outcomes (Visual Analogue Score (VAS) and Oswestry Disability Index (ODI)).ResultsA total of 103 revision surgeries (mean age 58.3 years; 54 females, 49 males) were included. Those in Group A were revised within two years (n=50, 49%); Group B were revised between two to five years (n=25, 24%); and Group C were revised more than five years after the index surgery (n=28, 27%). In Group A, revisions were predominantly in patients who had fusion procedures in the first surgery. In contrast, Group C had more patients whose index procedure was non-fusion. Analysis of the preoperative radiographs of previous surgeries revealed overlooked ASD, foraminal stenosis, and inadequately decompressed stenotic segments. Statistically significant improvement in pain and functional outcomes was noted at the six-month follow-up.ConclusionPrevention of early revision lumbar surgery requires adequate decompression during the primary procedure, identification and prophylactic treatment of partially stenotic adjacent levels, and recognition and decompression of the foraminal stenosis.

Nevus lipomatosus superficialis (NLS) is a rare benign cutaneous hamartoma characterized by mature adipose tissue in the dermis. Clinically, it appears as soft, skin-colored or yellowish papules or nodules. It manifests in classical or solitary form, often misdiagnosed as lipofibroma, acrochordon, or papillomas. NLS is frequently misdiagnosed because its clinical and cytological features overlap with those of subcutaneous lipomatous lesions, while its defining characteristic (ectopic adipocytes within the dermis) is only evident on histopathological examination. This study describes the clinico-histopathological features of the solitary variant ofNLS to minimize diagnostic inaccuracy. Fifteen histopathologically confirmed NLS caseswere studied over two years, with clinical presentations and morphology of lesions systematicallyanalyzed and tabulated. A strong female preponderance was noted (male-to-female ratio = 1:14), with a mean age of 39.5 years.The thigh (five cases, 33.3%) and buttocks (four cases, 26.7%) were the most common sites, followed by the back (two cases, 13.3%) and the nape, axilla, inguinal region, and shoulder (each 6.7%). All lesions were of the solitary variant. Histology showed epidermal atrophy and mature adipocytic dermal lobules mixed with collagen. Clinically, all cases were misdiagnosed, with NLS being confirmed only after histopathological examination. NLS is a rare cutaneous malformation. In this study, all histopathologically diagnosed NLScases were of the solitary variant with a female predominance. However, larger studies are needed to confirm these patterns. Accurate clinical and histopathological recognition is crucial to avoid misdiagnosis with other common benign skin lesions.

Objectives Traditionally, fasting before a contrast-enhanced computed tomography (CECT) scan was considered necessary due to the concerns of nausea, vomiting, and aspiration pneumonia. As per the recent international guidelines, fasting is not recommended prior to routine CECT; and with the use of non-ionic iodinated contrast media (ICM), the frequency of adverse reactions has decreased significantly. Our aim is to prospectively evaluate the effect of non-fasting on the occurrence of nausea, vomiting, aspiration pneumonia, and other acute adverse reactions (AARs) in patients undergoing non-emergent CECT and correlating these complications with the time of food ingestion, type (solid/liquid), and the quantity of food ingested. Material and Methods A 100 adult non-fasting patients who underwent a non-emergent CECT scan after intravenous injection of non-ionic ICM (iohexol-350 mg I/ml), were observed for 1 hour for the occurrence of AARs. The time, type, and quantity of food ingested prior to CECT were recorded. Results Four patients out of 100 (4%) developed mild emetic complications with spontaneous resolution within 1 hour. No aspiration pneumonia, urticaria, bronchospasm, or any severe AARs were seen. No statistically significant correlation was found between the time of food ingestion, type and quantity of food ingested, and the occurrence of AARs. (p = 0.61, 0.388, and 0.255, respectively). Conclusion No significant AARs or aspiration pneumonia were seen in non-fasting patients undergoing non-emergent CECT with non-ionic ICM, irrespective of the time of food ingestion, type, or quantity of food ingested.

Background Subarachnoid block is the most widely used technique for lower limb surgeries because of its cost-effectiveness, good muscle relaxation, reliability, prolonged analgesia and early ambulation. Clonidine as an adjuvant for subarachnoid block may improve analgesia. So, in this study, we propose to evaluate the analgesic efficacy of hyperbaric levobupivacaine with or without clonidine in patients undergoing surgery for femoral fractures. Secondarily, we also compared sensory and motor block characteristics and noted side effects. Methods Subarachnoid block was given in sitting position under all aseptic precautions at the level of L2-L3or L3-L4intervertebral space as per the standard protocol. Intrathecal drug was given according to the group allotted as follows: Group-LC: 15 mg of 0.5%hyperbaric levobupivacaine (3 ml) + 15 mcg of clonidine (0.1 ml); Group-LN: 15 mg of 0.5% hyperbaric levobupivacaine (3 ml) + normal saline (0.1 ml) The total volume of intrathecal drug was 3.1 ml in both groups. Block characteristics were assessed using loss of pinprick sensation for sensory block and Modified Bromage Scale (MBS) for motor block. Hemodynamic variables were also recorded. Results The demographic profiles of both groups were comparable to each other with respect to gender, American Society of Anesthesiologists (ASA) grade, weight and height of patients. The duration of effective analgesia was 166.67 ±31.72min in group LC and98.80 ±8.99 min in group LN (p <0.001). The difference was statistically significant. The mean time of onset of sensory block was 6.53 ±1.60 min and 4.00 ±1.69 min (p =0.001); the mean time to achieve a maximum height of the sensory block was 11.53 ±3.72 min and 6.67 ±1.45 min (p <0.001) in groups LC and LN, respectively and were statistically significant. The median maximum block height was comparable in both groups. The maximum motor block achieved and motor block at the time of rescue analgesia were comparable in both groups. Intraoperative and postoperative hemodynamic parameters (heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP)) were comparable among the groups LC and LN, except in DBP at 90 mins, where in group LC the mean was 77.00 ±6.32 min and in group LN it was 81.73 ±6.25 min, which was statistically significant. Sedation scores were comparable in both groups intraoperatively and postoperatively. None of the patients had any sedation in either ofthe groups, and all the patients were easily arousable in group LC and group LN, respectively. No major side effects were observed in either of the groups except one patient (6.7%) in group LC and one patient (6.7%) in group LN developed nausea, and five patients (33.3%) in group LC and three patients (20.0%) in group LN had shivering, which was managed promptly. Conclusion Addition of 15 mcg of clonidine to 3 mL (15 mg) of 0.5% hyperbaric levobupivacaine provides a longer duration of effective analgesia with minimal side effects.