Suprapatellar versus infrapatellar approach for intramedullary nailing in tibial shaft fractures

Background: Tibial shaft fractures accounts about 2% of all adult fractures and it is a common traumatic injury caused by high-energy trauma. The intra-medullary nail fixation either by Suprapatellar approach or Infrapatellar approach has been reported to be a successful surgical procedure for the treatment of proximal tibia fractures. Aim was to compare the clinical and functional outcomes of tibial shaft fractures treated with IMN using the suprapatellar and infrapatellar methods. Methods: The present prospective comparative study was conducted to compare the clinical and functional outcomes of tibial shaft fractures managed by Suprapatellar or Infrapatellar intramedullary nailing technique. This study was conducted in the Post Graduate Department of Orthopedics in SKIMS, MCH Bemina, Srinagar for a period of 02 years from May, 2020 to May, 2022. A total of 40 patients with tibial shaft fracture were included in the study. The statistical analysis was done using SPSS (Statistical Package for the Social Sciences, SPSS Inc., v.16). Results: It was observed that the majority of the participants (37.5%) were in 31-40 year’s age group, there were male predominance with the male to female ratio 2.33:1. In SP technique excellent results were observed in 80% of the study subjects whereas in IP technique, 70% patients had excellent results. Conclusions: It is concluded that SP technique shows better results as compared to IP technique in the management of tibial shaft fracture.

Outcomes of usage of polypropylene mesh in TAPP hernia repair

Background: Repair of hernia has seen a paradigm shift from open technique to laparoscopic technique. Laparoscopic transabdominal preperitoneal mesh hernioplasty is the latest technique with several advantages over open repair. Polypropylene (PP) mesh is the most frequently preferred product, as are easily and cheaply available, provide enough strength for the technique with good biocompatibility and less tissue reaction. Objective was to study the outcome of usage of polypropylene mesh in TAPP hernia repair. Methods: It was a prospective study on patients with diagnosis of inguinal hernia and underwent TAPP hernia repair with polypropylene mesh. Results: Total of 60 patients were included. Majority of the patients (18; 30%) were in age groups of 46-55 years and 56-65 years. 67% cases of inguinal hernia were of indirect type, 30% direct type and 3% both direct and indirect. Right-sided inguinal hernia (57%) was more frequent, followed by left sided (23%) and bilateral (20%). Average time taken was 72 to 98 minutes with a mean of 81.33 minutes in the surgery for unilateral repair and 90 to 103 minutes with a mean of 97.66 minutes for bilateral repair. 40 (67%) patients returned to work within 2 weeks of surgery. Conclusions: Inguinal hernia repair is a common surgical procedure performed on daily basis around the world. Delay in treatment can lead to complications. Laparoscopic approach has shown clear advantages regarding less postoperative pain, numbness, fast return to normal activities and decrease in the incidence of wound infection and hematoma. Polypropylene has proven physical, chemical and biological properties and is currently the most widely used allograft in laparoscopic inguinal hernias.

Outcomes of usage of polypropylene mesh in TAPP hernia repair

Background: Repair of hernia has seen a paradigm shift from open technique to laparoscopic technique. Laparoscopic transabdominal preperitoneal mesh hernioplasty is the latest technique with several advantages over open repair. Polypropylene (PP) mesh is the most frequently preferred product, as are easily and cheaply available, provide enough strength for the technique with good biocompatibility and less tissue reaction. Objective was to study the outcome of usage of polypropylene mesh in TAPP hernia repair. Methods: It was a prospective study on patients with diagnosis of inguinal hernia and underwent TAPP hernia repair with polypropylene mesh. Results: Total of 60 patients were included. Majority of the patients (18; 30%) were in age groups of 46-55 years and 56-65 years. 67% cases of inguinal hernia were of indirect type, 30% direct type and 3% both direct and indirect. Right-sided inguinal hernia (57%) was more frequent, followed by left sided (23%) and bilateral (20%). Average time taken was 72 to 98 minutes with a mean of 81.33 minutes in the surgery for unilateral repair and 90 to 103 minutes with a mean of 97.66 minutes for bilateral repair. 40 (67%) patients returned to work within 2 weeks of surgery. Conclusions: Inguinal hernia repair is a common surgical procedure performed on daily basis around the world. Delay in treatment can lead to complications. Laparoscopic approach has shown clear advantages regarding less postoperative pain, numbness, fast return to normal activities and decrease in the incidence of wound infection and hematoma. Polypropylene has proven physical, chemical and biological properties and is currently the most widely used allograft in laparoscopic inguinal hernias.

Acceleration of cutaneous wound healing by Lucilia sericata maggots in diabetic Wistar rats

@#The study was aimed to evaluate the effectiveness of maggot therapy in healing of cutaneous infected wound in streptozotocin (STZ) induced diabetic Wistar rat. For live maggots, the sterilized eggs of Lucilia sericata were obtained from colonies established in laboratory. Diabetes model was established in 48 male Wister rat by intra-peritoneal injection of STZ at the dose of 60 mg/kg body-weight. Cutaneous wounds exposed with mixed colonies of bacteria like Staphylococcus aureus, E. coli and Pseudomonas aeruginosa were prepared in all rat. The animals equally divided in 4 groups with 12 rats each being presented as treatment group of control, antibiotic, maggot and maggot with antibiotic in combination. All treatments were done once and hold for 24 hours. Wound kinetics and bacterial bio burden were measured at weekly interval to till complete healing. Significant reduction in wound area with maximum contraction was found (>95%) in maggot treated group when compared to antibiotic treated (79%) and control (72%). In maggot as well as maggot and antibiotic in combination group showed early elimination of bacterial bio-burden 7.88±0.03log CFU/ml to 1.12±0.65log CFU/ml and 7.86±0.04) log CFU/ml to 1.54±0.52log CFU/ml respectively in three weeks of time. Early healing indication was also experienced on histomorphological examination of wounded tissue of maggot treated groups by early and better epithelialization, collagenation and neovascularization with complete healing of wound in three weeks in comparison to antibiotic and control respectively. However, the present study did not show any difference in healing of wound with use of maggot alone or in antibiotic combination. Live maggot of Lucilia sericata effectively lower bacterial bioburden and and accelerate healing of infected cutaneous wound in diabetic conditions.

A Micro Level Investigation of Costs & Returns of Different Agro-ecosystems in Kashmir Region of Jammu and Kashmir: India

The basic objectives of the study were to enquire in to the involvement of various types of costs, the returns per rupee invested and the benefit thereof in different agro-ecosystems in the state of Jammu and Kashmir in general and valley of Kashmir in particular, especially the sampled districts. This study was based upon primary and secondary data. A multi-stage random sampling was utilised for collection of date from 432 respondents of four different agro-ecological zones. For major crops, the cost of cultivation were estimated by concept utilised by Commission on Agricultural Costs and Prices (CACP), Government of India. The results revealed that fruit crop agro-ecosystem is highly remunerative than field crop and crop agro-ecosystems, though the fruit crop involve huge of investment in terms of different costs. The livestock based agro-ecosystem is also dominant in some parts of the Kashmir region with declining trend. The results revealed that the gross returns of paddy and apple, livestock and cash crop were Rs. 23250, Rs. 321000, Rs. 108920 and 106915 respectively. This study had its applicability in the daily routine life of any household dwelling in the sampled agro-ecosystems. The study could be of utmost importance in selecting the crop in which the region/agro-ecosystem had specialisation or absolute advantage.

Demographic Profile of Cervical Cancer: A Retrospective Study Conducted in Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India

Introduction: Worldwide, cervical cancer remains the most common gynecological cancer and the fourth most commonmalignancy in women, with over 526,000 women globally developing this tumor as reported in 2015 and 239,000 women dyingof the disease every year. To date, there are limited data of cervical cancer in Kashmir, India.Objectives: The aim of the present study was to analyze the demographic spectrum of cervical cancer in Kashmir.Materials and Methods: This was a retrospective study. All the patients who had histopathologically confirmed cervical cancer,registered at Regional Cancer Center of Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, were included, between2008 and 2015. All the patient characteristics including age, presentation, type of cancer, stage of cancer, parity, and treatmentreceived in each case were studied in detail.Results: The present study included 120 patients of cervical cancer. The median age of patients was 51 years. Majority of ourpatients were multiparous (88.3%) and from a rural background (74%). The most common presenting complaint was abnormal vaginalbleeding (70%) followed by abdominal pain (19%). Squamous cell carcinoma was the most common type of cervical carcinomaseen in 95% of patients followed by adenocarcinoma (5%). Most of the patients (66.67%) presented at late Stages (II, III, and IV).Conclusion: Early detection will reduce the number of deaths of cervical cancer patients. Asignificant number of cervical cancer patientsin Kashmir present with an advanced stage of disease. Cervical cancers are observed at a middle age group that is >40 years of age.People should be educated for an early consultation for symptoms, and high-risk individuals should be encouraged for screening. Thehealth programs about cervical cancer should be carried out in open places to give more information about cervical cancer to the public.

Diagnostic Accuracy of Different Bedside Clinical Methods in Evaluation of Peripheral Neuropathy in Patients of Diabetes: Experience at a Tertiary Care Center

Background and Objectives: At present, the gold standard for diagnosis of diabetic peripheral neuropathy is biothesiometry. Sincethe data are sparse comparing the biothesiometry with commonly used bedside tests, we conducted this study to evaluate theclinical accuracy of simple bedside clinical screening tools for evaluation of peripheral neuropathy in patients of diabetes mellitus.Materials and Methods: Atotal of 120 patients with diabetes mellitus referred from the endocrinology department, from August2014 to July 2017 were included in this study. A detailed clinical assessment including diabetic neuropathy symptom (DNS)score, diabetic neuropathy examination (DNE) score, ankle reflex, vibration sensation with a 128 Hz tuning fork, and 10 gSemmes-Weinstein monofilament, and biothesiometry was done in all the subjects.Results: The prevalence of peripheral neuropathy was 36% with biothesiometry. Only 33.33% of patients followed foot carepractices in the study population. Monofilament was the most sensitive and accurate of all the diagnostic tests for the evaluationof peripheral neuropathy in diabetes patients. On statistical analysis correlations observed between the biothesiometry andthe DNE score (r = 0.572, P < 0.00018) and DNS score (r = 0.436, P < 0.0004) and absent tuning fork sensation (r = 0.510;P < 0.0007), monofilament sensation (r = 0.713; P < 0.0002) and ankle reflex (r = 0.456, P = 0.0002) were significant.Interpretation and Conclusions: we concluded that simple bedside tests are useful for diagnosing peripheral neuropathy indiabetes patients including those in whom foot care practices are not followed.

Economic Appraisal of Water-Ecosystem in Jammu and Kashmir: India

Aims: The aims of the current paper is to provide a comparative analysis of the water ecosystem in the state of Jammu & Kashmir in India and to highlight economic potentiality of the two nerve tributaries; “Dal Lake” and “River Jhelum” to the farmers and other communities of the Kashmiri society. Study Design: The temperate region of Kashmir valley is bestowed with many water bodies in the form of springs, lakes and rivers. Kashmir region is world famous for its lakes viz; “Dal Lake”, “Wulur Lake”, “Mansbal Lake”, “Anchar Lake”, “Nigeen Lake”; springs viz; Kokarnag, Verinag, Achabal and “River Jhelum” etc. “Dal Lake” and “River Jhelum” are known to be the nerve tributaries of the valley and various communities are dependent on these water bodies for their livelihood. Methodology: Contingent valuation method and willingness to pay techniques were used to analyse the data and interpret the results. Results: The results revealed that economic value associated with the selected water bodies was worth millions of US$. Most of the population in the valley depends on these water bodies for their livelihood. In addition, the results reveal that over the years, pollution and encroachment of these water bodies has increased manifold reducing the width, depth and recreational value of these water bodies. Though every stakeholder is willing to pay for the restoration of these water bodies, however, little or no attention is being paid by the local government towards their, management, sustenance and conservation. Conclusion: The study concludes that over the years, due to growth of population in the valley along with the ever increasing influx of floating population in terms of tourist arrivals, the selected water bodies (Dal Lake & River Jhelum) came under heavy stress, culminating into the deterioration of their aesthetic and recreational value besides drastic reduction in their revenue generation for their poor water quality and mismanagement. The restoration of these water bodies, which in addition of providing employment to the stakeholders in huge numbers also generate revenue worth millions of US$, demands devising a pragmatic policy by the government towards their conservation and restoration of their lost glory through efficient management and monitoring system.

Retromandibular Approach for Subcondylar Fractures: A Prospective Study

Background: Condylar fractures accounts for 25-50% of all mandibular fractures. It can be extracapsular or intracapsular, nondisplaced, displaced, deviated, or dislocated from the disc. Objective: To evaluate the retromandibular transparotid approach for open reduction & internal fixation of subcondylar fractures for post-operative occlusal status, stability of fixation & postoperative complications. Material and Methods: The prospective study was performed on 24 patients (18 male and 8 females) sustaining 26 subcondylar fractures who were treated surgically utilizing retromandibular transparotid incision. Results: The most common etiology of injury was road traffic accidents in 62.5% patients. Satisfactory anatomic reduction and occlusion was achieved in all patients. The incidence of transient facial nerve injury was 16.67%. The facial nerve returned to normal function in 3 months in all the 4 affected patients. Conclusion: The incision provides easy visualization of the subcondylar region from the posterior edge of the ramus to the sigmoid notch, allows the perpendicular placement of screws to the fracture site, with minimal post operative complications and satisfactory esthetic results.

Therapeutic use of Lucilia sericata maggot in controlling bacterial bio-burden in Rat wound model

@#Delayed wound healing due to extraneous bacterial contamination, antibacterial resistance and other associated factors are of great concern in dealing patients having chronically infected wound. Medicinal properties of certain maggots of Calliphoridae family are known for its effective wound debridement therapy. The objective of the study was to evaluate the wound healing potential of maggots of Lucilia sericata in an experimentally infected cutaneous wound model in Wistar rat. The study was carried out by using male Wistar rats (n=48) by creating excisional wounds and later contaminated with mixed population of gram positive and gram-negative bacteria. Animals were divided randomly in to four groups with 12 individuals each, being denominated as control, antibiotic treated, maggot treated, and antibiotic plus maggot combination treated group. Ten pre-sterilized maggots were applied per centimetre square wound bed for 24 hours. Different wound kinetics in L. sericata maggot treated wounds revealed significant reduction in wound area with maximum contraction, early elimination of bacterial bioburden as compared to group of infected control and group of rats receiving only antibiotic treatment. The histopathological examination of wounded tissue of maggot treated groups showed early and better epithelialization, collagenation and neovascularization with complete healing of wound in two weeks. The maggot effects on healing when used singly or in combination with antibiotic were recorded to be similar. The results of the present study clearly demonstrate that the maggots of L. sericata possesses a definite antibacterial action along with removal of dead tissues and effectively reduced the bacterial bio-burden in infected wound and induced wound healing quickly.

Aural hygiene practices among underprivileged children of Delhi.

Background. Though ear hygiene is important for proper hearing, it is usually neglected. Improper ear care practices may have serious consequences such as loss of hearing. In childhood, loss of hearing may affect learning and development. There is scarcity of information on ear care practices in the community in India. We aimed to ascertain the magnitude of problems related to aural hygiene and assess ear care practices among children of schoolgoing age in a resettlement colony of Delhi. Methods. A cross-sectional community-based survey was done among 1398 children 5–14 years of age. The houses were selected by systematic random sampling and all eligible children in the selected house were interviewed and examined. The data were analysed using SPSS version 12 and chi-square test was used to ascertain significance between two variables. Results. Almost two-thirds (60%; 834) of the children gave a history of themselves or an elder cleaning the ear using unhealthy methods. Earbuds were used by 21.7% (304) of children. Match and broomsticks were used for cleaning by 18.3% (256) and 3% (43) of children, respectively. One hundred and fifty-nine children (11.3%) were applying oil to clean the ear canal. Ear cleaning with unhealthy means was significantly higher (56% v. 44%, p<0.03) among children belonging to low socioeconomic strata. There was a significant association between unhealthy ear cleaning practices and middle ear infection (p<0.001). Conclusion. A majority of children practised unhealthy/ not recommended methods for cleaning their ear. There is a need to raise awareness about healthy ear cleaning practices in the community. Natl Med J India 2015;28:280–1

Collagen: Animal Sources and Biomedical Application.

Collagen is the sole most profuse protein in the animal kingdom. It has been subjected to various studies from time immemorial. Its applications are numerous and have been extracted from various sources such as land animals (mainly bovine and porcine) and birds. Although collagen sources are abundant the outbreak of varied diseases among land animals posed a threat to its utilization in our daily life. Thus a probe for an alternative source began which in turn revealed the immense untapped marine source. The present article deals with a brief description of collagen its characteristics,chemistry,common extraction procedure, application in various fields and sources. A lot of studies have been carried out on various land animals, birds and marine organisms and this review sums up the work performed to date in a concise manner.

Analysis of brain tumors in Kashmir Valley - A 10 year study.

Background: Geographically Kashmir valley is isolated from the rest of the country. It has a different climate with people having different social and dietary habits. Gastric cancer, esophageal, and skin (Kangri) cancer have a higher prevalence but there is little data available on the cancers of brain. Objectives & Methodology: Aim was to study brain tumors prospectively and retrospectively, to analyse brain tumors geographically and to analyse the age and sex ratio of brain tumors in Kashmir valley. In this Retrospective and Prospective study, retrospectively (initial seven years) all patients were analyzed for their clinical symptoms, age, sex, residence, histopathologic characteristics of tumors. Prospectively (later three years) after get-ting the radiological diagnosis pathological diagnosis was arrived by procedures like open, stereotactic, and endoscopic procedures. All patients were then analysed for age, sex, residence, signs and symptoms and histopathological characteristics. Follow up was done for gliomas. Mortality and morbidity was analysed for gliomas in these 3 years. Patients who lost the follow up were considered dead. Out of 1730 patients included in our study, there were 1031 males and 699 females. The most common age group was between 41-50 years. Results: The most common tumor was gliomas followed by meningiomas. Gliomas were most common in men and meningiomas in females. Out of all the histological grades in gliomas, the glioblastoma multiforme (GBM) was the most common, and frontal lobe was the commonest anatomical site involved. The most common symptom in our study was headache followed by vomiting.

Cystic Hygroma of Wrist.

Cystic hygroma is the rare congenital lesion. This is a cystic variety of lymphangioma. Cystic hygroma arising outside of the cervicofacial, thoracic, and abdominal areas are extremely rare. Wrist is a very rare site for occurrence of cystic hygroma. Presentation depends on site of location of cystic hygroma. A case of cystic hygroma of wrist in a child is reported. This child presented with painless swelling of left wrist. Excision of cyst was done. This is first case report of literature reporting occurrence of cystic hygroma on wrist.

Inner preputial flap as tunica albuginea replacement in the management of previously untreated fracture of the penis

To assess the efficacy of an inner preputial skin flap as replacement for the tunica albuginea of the corpus cavernosum after excision of fibrous plaque. Patients and Methods In this retrospective study we evaluated 5 men who presented with impotence; chordee; painful erection and/or painful coitus after previously undiagnosed or untreated penile fracture. In two patients soft tissue X-rays suggested calcification of the plaque; while ultrasonography revealed extension of fibrosis in four cases. In all patients the plaque was excised and the defect in the tunica albuginea was closed with an inner preputial pedicle skin flap. Results The flaps had taken well in all cases at 3 months follow-up and all patients reported having normal sexual intercourse. Conclusion Surgical excision is the treatment of choice for management of symptomatic fibrous plaques occurring in undiagnosed; untreated or conservatively managed penile fracture. A defect of more than 1.5 cm after excision of the plaque requires tunica replacement; and an inner preputial flap is a good replacement

Occurrence of Cucumber mosaic virus on vanilla (Vanilla planifolia Andrews) in India.

Cucumber mosaic virus (CMV) causing mosaic, leaf distortion and stunting of vanilla (Vanilla planifolia Andrews) in India was characterized on the basis of biological and coat protein (CP) nucleotide sequence properties. In mechanical inoculation tests, the virus was found to infect members of Chenopodiaceae, Cucurbitaceae, Fabaceae and Solanaceae. Nicotiana benthamiana was found to be a suitable host for the propagation of CMV. The virus was purified from inoculated N. benthamiana plants and negatively stained purified preparations contained isometric particles of about 28 nm in diameter. The molecular weight of the viral coat protein subunits was found to be 25.0 kDa. Polyclonal antiserum was produced in New Zealand white rabbit, immunoglobulin G (IgG) was purified and conjugated with alkaline phosphatase enzyme. Double antibody sandwich-enzyme linked immunosorbent assay (DAS-ELISA) method was standardized for the detection of CMV infection in vanilla plants. CP gene of the virus was amplified using reverse transcriptase-polymerase chain reaction (RT-PCR), cloned and sequenced. Sequenced region contained a single open reading frame of 657 nucleotides potentially coding for 218 amino acids. Sequence analyses with other CMV isolates revealed the greatest identity with black pepper isolate of CMV (99%) and the phylogram clearly showed that CMV infecting vanilla belongs to subgroup IB. This is the first report of occurrence of CMV on V. planifolia from India.

Coronary artery ectasia: angiographic, clinical profile and follow-up.

Out of 3200 coronary angiograms we reviewed, there were 144 cases of coronary ectasia--an incidence of 4.5 percent. Among these, 122 were associated with atherosclerotic coronary artery disease, i.e. coronary stenosis more than 50 percent (group A) and 22 not associated with coronary artery disease (group B). The patients in groups A and B were compared with age- and sex-matched patients (group C) (n=100) who had coronary artery disease alone without ectasia. The incidence of ectasia was not increased in patients with thoracoabdominal aortic aneurysm i.e. 2/154 (1.8%) or in patients with peripheral occlusive vascular disease i.e. 5/161 (3.1%). Ectasia was typed according to a modified version of the criteria proposed by Markis et al. Type II was the commonest, followed by type I, III and IV. Right coronary artery was the most commonly involved vessel by ectasia followed by left circumflex, left anterior descending artery and left main coronary artery. Diffuse ectasia was seen more frequently in right coronary artery and localised ectasia in left anterior descending artery. Patients in groups A and B had similar epidemiological characteristics, though more patients with ectasia alone (group B) had better left ventricular function and negative stress tests. The patients in group A had a similar incidence of previous myocardial infarction, coronary risk factor profile, treadmill exercise test status and severity of coronary artery disease when compared to group C. On a mean follow-up of 3+/-1.2 years, all the three groups had similar event rates.

Teeth and numerology from zodiac signs. A correlative study.

Comparative anatomical descriptions have been time and again mentioned in the literature. Based on these aspects, an attempt is made to correlate the morphological features of the human teeth, the zodiac sun signs and numerology. This unique study (first ever of its kind) is also done with a purpose as to whether a particular 'Zodiac Sunsign' or numerology can predict about an individual dental health, the same way the future predictions are being made. It was quite interesting to note that there are few definite attributable dental morphological traits and health to the specific sun signs and numerology.

Saccular coronary aneurysms: angiographic and clinical profile and follow-up of 22 cases.

Saccular coronary aneurysms are defined as aneurysms with the transverse dimension at least 1.5 times the longitudinal dimension. Out of 3,200 coronary angiograms reviewed, there were 22 patients (20 males) with saccular coronary aneurysms (totalling 25 aneurysms). The morphology of the aneurysms, the extent and severity of associated coronary lesions, the clinical profile and follow-up data of these patients were analysed. Aneurysms were located in left main coronary artery 3 (12%), left anterior descending coronary artery 13 (52%), right coronary artery 5 (20%) and left circumflex 4 (16%). There were 5 large aneurysms (> 15 mm in diameter) (1 in left main coronary artery, 2 each in right coronary artery and left anterior descending coronary artery) averaging 32 mm in size. Fifteen aneurysms had significant coronary artery stenosis located proximal to it, supporting the theory of post-stenotic dilatation as the aetiology of aneurysm formation. Two patients had associated muscle bridges distal to the aneurysm; 20 had atherosclerotic coronary artery disease and one had coronary artery ectasia. Five patients were lost to follow-up, which ranged from 1 year to 19 years (mean 5.3 +/- 4.1 years). No patient had history suggestive of rupture of the aneurysm on follow-up. Two patients had myocardial infarction in the territory of the vessel with the aneurysm. Rest of the patients were in NYHA class I/II. One large right coronary artery aneurysm was subjected to aneurysmectomy due to symptoms of tricuspid valve obstruction. One left main coronary artery aneurysm measuring 12 mm, on follow-up of 19 years increased in size to 45 mm, in addition the patient developed a right coronary artery aneurysm. Coronary risk factor profiles in the 20 patients with atherosclerotic coronary artery disease and aneurysms were similar to age- and sex-matched control population with atherosclerotic coronary artery disease without aneurysms.