Introduction: In patients with diabetic ketoacidosis (DKA), the American Diabetes Association guidelines support administering long-acting insulin (LAI) at the time of conversion from IV insulin to subcutaneous rapid acting insulin (RAI). Challenges with LAI timing in children may complicate this transition, and LAI may be administered earlier in the DKA course at some institutions. Limited evidence currently exists assessing the value of this early LAI administration while the patients are still in DKA. The purpose of this study was to assess the benefit and safety of early LAI in pediatric DKA. Methods: This single-center retrospective cohort study included patients < 21 years old admitted to the PICU in DKA on an IV insulin drip. Patients meeting inclusion criteria were divided into two groups: early LAI (administered >4 hours prior to conversion to RAI) and late LAI (administered within 2 hours of RAI). Each group was subdivided into DKA severity (moderate vs severe) and new onset vs known diabetes. The primary outcome of the study was to compare the time to DKA resolution, and secondary outcomes evaluated the total IV insulin doses received, and incidence of adverse effects and complications: hypoglycemia, hypokalemia, cerebral edema, and recurrence of DKA. Results: A total of 372 encounters were included in the preliminary assessment (224 in early LAI and 148 in late LAI groups). Baseline characteristics were similar between both groups. The time to DKA resolution was significantly longer (13 vs. 9.6 hours, p< 0.0001) and total dose of IV insulin significantly higher (65.7 vs. 44 units, p=0.0018) in the early LAI group. Rates of mild hypoglycemia and hypokalemia were significantly higher in the early LAI groups (33.5% vs. 21.6%, p=0.0134 and 42.4% vs. 14.2%, p< 0.0001, respectively). The trends in longer duration of DKA and rates of these adverse effects for the early LAI were also seen in the subgroups of new onset patients and with both moderate vs severe DKA. No differences were observed with severe hypoglycemia or hypokalemia, rates of cerebral edema or recurrence of DKA. Conclusions: Use of early LAI in pediatric DKA demonstrated no reduction in the time to resolution of DKA or total IV insulin dose regardless of severity of presentation, and increased risk of mild hypoglycemia and hypokalemia.

Diabetic ketoacidosis

10.1097/01.ccm.0000908132.53874.cd

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Infective Endocarditis in Hemodialysis Patients

The International Journal of Artificial Organs (2007)

Rahul Pandey Ramin Sam

Infective Endocarditis

10.1177/039139880703000409

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Human immunodeficiency-causing mutation defines CD16 in spontaneous NK cell cytotoxicity

Journal of Clinical Investigation (2012)

Jennifer T. Grier Lisa R. Forbes Linda Monaco-Shawver Jennifer Oshinsky T. Prescott Atkinson

The Fc receptor on NK cells, FcγRIIIA (CD16), has been extensively studied for its role in mediating antibody-dependent cellular cytotoxicity (ADCC). A homozygous missense mutation in CD16 (encoding a L66H substitution) is associated with severe herpesvirus infections in rare patients. Here, we identified a new patient with this CD16 mutation and compared the patient's NK cells to those of the originally reported patient. Patients with the L66H mutation had intact ADCC, but deficient spontaneous NK cell cytotoxicity and decreased surface expression of CD2, a coactivation receptor. Mechanistic studies in a human NK cell line, NK-92, demonstrated that CD16 expression correlated with CD2 surface levels and enabled killing of a melanoma cell line typically resistant to CD16-deficient NK-92 cells. An association between CD16 and CD2 was identified biochemically and at the immunological synapse, which elicited CD16 signaling after CD2 engagement. Stable expression of CD16 L66H in NK-92 cells recapitulated the patient phenotype, abrogating association of CD16 with CD2 as well as CD16 signaling after CD2 ligation. Thus, CD16 serves a role in NK cell-mediated spontaneous cytotoxicity through a specific association with CD2 and represents a potential mechanism underlying a human congenital immunodeficiency.

CD16

Fc receptor

Immunological synapse

10.1172/jci64837

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PWE-199 Diagnostic Radiation Exposure in Patients with Crohn’S Disease Treated with Infliximab

Gut (2013)

H-L Ching Rahul Pandey F Chariah Gideon Lipman Matthew Train

Introduction

Exposure to radiation from diagnostic imaging is thought to be associated with an increase in cancer risk. Patients with Crohn’s Disease (CD) frequently require x-ray exposure throughout the course of their illness. Studies have quantified cumulative radiation exposure in patients with CD¹. However, as far as we know, there has only been one study that has identified infliximab as an independent risk factor for increased radiation exposure². We aimed to quantify all imaging and associated radiation exposure for this subset of patients in our institution.

Methods

Our unit is in a district hospital serving a population of 500,000 across 2 sites. All patients with CD who have received infliximab from January 1997 to January 2013 were identified from our hospital databases. Diagnostic imaging records were also retrieved from the databases. Using local protocols, a mean effective dose for each imaging modality was calculated. The cumulative effective dose (CED) per patient was calculated as the sum of the mean effective dose for all imaging modalities. The mean diagnostic radiation exposure per year = CED/years of follow-up.

Results

131 patients (52% female, mean age 46 years) were included in the study. Total number of imaging procedures was 624 (plain abdominal film = 351, CT abdomen/pelvis = 168, barium study = 105). Other imaging modalities included MRI abdomen/pelvis = 72 and abdominal ultrasound = 65. Average total number of imaging per patient was 5 (plain abdominal film = 3, CT abdomen/pelvis = 1, barium study = 1). The total CED for all imaging was 1828.1 mSv (85% attributed to CT imaging). The mean CED per patient was 14.0mSv (range 0–171.9mSv) with the mean diagnostic radiation exposure per year being 2.4mSv/year (range 0–28.7mSv/year).

Conclusion

Imaging requests in patients with CD is high, particularly when they have received infliximab. In spite of concerns about radiation risk, 93% of our patients have CED less than 50mSv exposure, a level considered to be associated with a low cancer risk. However, most patients are young and are likely to accumulate more radiation exposure over time. The move towards more specialised care should lead to reduction in use of CT scans and increased use of MRI and ultrasound studies.

Disclosure of Interest

None Declared.

Reference

Peloquin JM, et al. Diagnostic ionising radiation exposure in a population-based cohort of patients with inflammatory bowel disease. Am J Gastro 2008; 103:2015–22 2. Desmond AN, et al. Crohn’s disease: factors associated with exposure to high levels of diagnostic radiation. Gut 2008; 57:1524–1529

10.1136/gutjnl-2013-304907.487

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Interface healing and its correlation with visual recovery and quality of vision following small incision lenticule extraction

Indian Journal of Ophthalmology (2018)

Sheetal Brar Sri Ganesh Rahul Pandey Archana Pawar

Purpose: To study the time course of interface healing and its correlation with visual acuity, modulation transfer function (MTF), and aberrations after myopic small-incision lenticule extraction (SMILE) correction. Methods: Seventy-eight eyes of 78 patients (1 eye per patient) with a mean age of 25.7 years and mean spherical equivalent (SE) of −3.74D, undergoing bilateral SMILE procedure, were included in this study. On postoperative day 1, 2 weeks, and 3 months, dilated retroillumination photographs were taken and morphology of corneal interface was graded by comparing them with 5 standard templates representing 5 grades of interface roughness (IRG): IRG – 0 (clear), IRG – 1 (mild), IRG – 2 (moderate), IRG – 3 (severe), and IRG – 4 (severe IRG with Bowman's folds in visual axis). Pearson's correlations were computed to study correlation associations, and Wilcoxon signed-rank test was used for intragroup comparison of means. P ≤ 0.05 was considered statistically significant. Results: At 3 months, 90.70% eyes were Grade 0 while 9.30% eyes still had Grade 2 interface granularity. Mean IRG significantly improved from 2.47 ± 0.57 at day 1 to 0.62 ± 0.53 at 3 months (P = 0.00). At day 1, pre-SE showed a significant positive correlation with IRG; however, mean postoperative corrected distant visual acuity (CDVA, in decimal), corneal Strehl ratio (SR), and MTF showed weak but significant negative correlation with IRG (r2 = 0.28 for SE, −0.052 for CDVA, −0.017 for SR, and −0.39 for MTF, respectively, P < 0.05 for all correlations). At 2 weeks and 3 months, corneal MTF continued to show a significant negative correlation, whereas other parameters did not show any correlation with IRG. Conclusion: Visual quality and corneal MTF may be significantly affected by the IRG in the immediate postoperative period after SMILE and may take 3 months or more for complete recovery.

10.4103/ijo.ijo_775_17

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Effect of Eye Exercise on Myopia in Children Aged Between 10-15 Years- A Randomized Clinical Trial

International Journal for Advance Research and Development (2017)

Rahul Pandey Ritwiz Bihari Anamika Pandey

Background- Myopia is the most common refractive error of eye in school going children. There are many treatment option are available to prevent or treat the myopia but not yet well documented in physiotherapy. Objective- To find out the effect of eye exercise on myopia in children aged between 10-15 years. Study Design- A Randomized Clinical Trial Study setting- The setting were MMIMSR, Mullana-Ambala and Ashirwad Eye Hospital, Yamunanagar-Ambala. Participants- 50 subjects of both genders mean age of 12.86±1.48 years with diagnosed case of myopia were recruited through criteria based purposive sampling. Method- Consent was taken, random allocation done in to two groups’ Experimental (Exp) group and Control (Ctrl) group. Pre intervention optical power and CISS were taken by Nidek ARK 700A and CISS scale respectively. Exp group receive Palming exercise, Eye warm-up exercise, Cross crawl and Tibetan Eye exercise for three weeks five days per week and 20 mins per day, Ctrl group was advised to use spectacles or contact lenses on regular basis for three weeks. After three weeks of intervention post Optical power and CISS were taken and analyzed. Result- CISS score significantly reduced within both the group after treatment, but there was no significant change observed for optical power in ctrl group. However from end-point to follow-up a significant reduction in CISS occurred (P<0.001) in control group, and no significant change observed for optical power of RE and LE (P=0.13, 0.99 respectively). In contrast, the Exp group showed reduction of optical power (P<0.001), and CISS score (P<0.001).

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Effect of MET & MFR on Primary Open Angle Glaucoma in Adult aged between 15-30 years

International Journal for Advance Research and Development (2017)

Rahul Pandey

Background: Primary open angle glaucoma is one of the major cause of blindness and it have only surgical treatment and lifelong use of medication. Hence many side effects arise. To overcome this, the drugless approach is in practice but the importance of Muscle Energy Technique (met) and Myofacial (MFR) Release is not explored. Objective: To determine the effectiveness of MET and MFR on primary open angle glaucoma in primary open angle glaucoma. Setting: Tertiary care teaching hospital Methods: 12 subjects with Primary open angle glaucoma was recruited through criteria based convenience sampling for the study. The age ranges from 15-30 years. MET and MFR was given to the subjects30 mins/day, six days/week for three weeks. Intraocular pressure was assessed with Tonometer as dependent variable by Ophthalmologist. Pre and post treatment intraocular pressure change is established. Result(s): Pre IOP and Post are 23.11±1.98 mmHg and Post IOP is 20.05±.1.42 mmHg respectively. The mean pre-post difference is 3.1± 1.9 mmHg with significance difference of p< 0.001. Conclusion: MET and MFR reduce intraocular pressure and relieve from other symptoms.

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