Does Elevated Mean-Arterial Pressure Lead to Better Outcomes in Degenerative Cervical Myelopathy?- A Prospective, Pilot Randomized Control Trial.

STUDY DESIGN: Randomized Control Trial. OBJECTIVE: DCM refers to compression of spinal cord either due to static/dynamic causes or commonly, a result of combination of both. Number of variables exist, which determine prognosis post-surgery. Role of intra-operative blood pressure has not been analyzed in depth in current literature. Elevating MAP post SCI is widely practiced and forms a recommendation of AANS/CNS Joint Committee Guidelines. This led us to investigate role played by elevated MAP during surgery for DCM, in order to optimize outcomes. METHODS: This prospective randomized comparative pilot study was conducted at a tertiary care spine centre. 84 patients were randomly divided in two groups. Group 1 had intra-operative MAP in normal range. Group 2, had intra-operative BP 20 mmHg higher than preoperative average MAP with a variation of + 5 mmHg. Outcomes were recorded at 3 months, 6 months and 1 year by mJOA, VAS and ASIA scale. RESULTS: Neurological improvement was documented in 19/30 (63.3%) patients of hypertensive group compared to 16/30 (53.3%) patients of normotensive group. Improvements in mJOA scores were better for hypertensive group during the 1-year follow-up. Improvement in VAS scores were comparable between two groups, but at 1-year follow-up the VAS score of hypertensive groups was significantly lower. CONCLUSION: MAP should be individualized according to preoperative average blood pressure assessment of patient. Keeping intraoperative MAP at higher level (preoperative MAP + 20 mmHg) during surgery for DCM can result in better outcomes.

The Presence of Chronic Total Occlusion in Noninfarct-Related Arteries Is Associated With Higher Mortality and Worse Patient Outcomes Following Percutaneous Coronary Intervention for STEMI: A Systematic Review, Meta-Analysis and Meta-Regression.

Reperfusion therapy with percutaneous coronary intervention improves outcomes in patients with ST-elevation myocardial infarction. We conducted a meta-analysis to assess the impact of chronic total occlusion (CTO) in noninfarct-related artery on the outcomes of these patients. Comprehensive searches were performed using PubMed, Google Scholar, and EMBASE. The primary endpoint was the 30-day mortality rate, with secondary endpoints including all-cause mortality, repeat myocardial infarction, and stroke. Forest plots were created for the pooled analysis of the results, with statistical significance set at P < 0.05. A total of 19 studies were included in this meta-analysis, with 23,989 patients (3589 in CTO group and 20,400 in no-CTO group). The presence of CTO was associated with significantly higher odds of 30-day mortality [18.38% vs 5.74%; relative risk (RR), 3.69; 95% confidence intervals (CI), 2.68-5.07; P < 0.00001], all-cause mortality (31.00% vs 13.40%; RR, 2.79; 95% CI, 2.31-3.37; P < 0.00001), cardiovascular-related deaths (12.61% vs 4.1%; RR, 2.61; 95% CI, 1.99-3.44; P < 0.00001), and major adverse cardiovascular events (13.64% vs 9.88%; RR, 2.08; 95% CI, 1.52-2.86; P < 0.00001) than the non-CTO group. No significant differences in repeated myocardial infarction or stroke were observed between the CTO and non-CTO groups. Our findings underscore the need for further research on the benefits and risks of performing staged or simultaneous percutaneous coronary intervention for CTO in the noninfarct-related artery in patients with ST-elevation myocardial infarction.

A systematic review of association between use of hair products and benign and malignant gynecological conditions.

Hair products often contain chemicals like para-phenylenediamine (PPD) and endocrine-disrupting chemicals (EDCs); giving rise to concerns about the possible adverse effects such as hormonal disturbances and carcinogenicity. The objective of this systematic review was to evaluate the association between the use of different hair products and benign and malignant gynecological conditions. Studies were identified from three databases including PubMed, Embase, and Scopus, and evaluated in accordance with PRISMA guidelines. The risk of bias was assessed using the Newcastle-Ottawa Scale. A total of 17 English-language studies met the inclusion criteria. Associations of hair relaxer or hair dye use with breast and ovarian cancer were observed in at least one well-designed study, but these findings were not consistent across studies. Further sub-analysis showed 1.08 times (95 % CI: 1.01-1.15) increased risk of breast cancer in females with permanent hair dye use. Chang et al. reported strong association between uterine cancer risk and hair relaxer use (HR 1.8, 95 % CI: 1.12-2.88), with no observed association with hair dye use. Studies conducted by Wise et al. and James-Todd et al. for benign gynecological conditions; including uterine leiomyoma (IRR 1.17, 95 % CI: 1.06-1.30), early onset of menarche (RR 1.4, 95 % CI: 1.1-1.9), and decreased fecundability (FR 0.89, 95 % CI: 0.81-0.98) revealed positive associations with hair relaxer use, but these findings were based on small sample sizes. In summary, the available evidence regarding personal use of hair products and gynecological conditions is insufficient to determine whether a positive association exists.

Utility of Diffusion Tensor Imaging in Assessing Corticospinal Tracts for the Management of Brain Tumors: A Cross-Sectional Observational Study.

Introduction Intra-axial brain tumors are a significant health problem and present several diagnostic and treatment challenges. Conventional magnetic resonance imaging (MRI) has posed several limitations, such as the inability to delineate the detailed anatomy of fibers in structures like the brainstem and the inability to accurately judge the extent of tumor infiltration. Diffusion tensor imaging (DTI), based on the concepts of isotropic and anisotropic diffusion, is capable of visualizing and segmenting white fiber bundles in high detail and providing crucial information about tumor boundaries, extent, neighboring tracts, and more. This information can be very useful in initial non-invasive diagnosis, preoperative tumor grading, biopsy planning, surgical planning, and prognosis. Methods and materials This is a cross-sectional observational study in a tertiary care setup, conducted over a one-year period. The study was performed in Seth Gordhandas Sunderdas Medical College (Seth G.S. Medical College) and King Edward VII Memorial Hospital (K.E.M. Hospital), a tertiary care hospital located in Mumbai, India. Fiber tractography was performed and was used to visualize the corticospinal tracts passing through the length of the brainstem. Changes in the degree of infiltration, destruction, and displacement of the corticospinal tracts were observed carefully. Adult patients who were diagnosed with brain tumors, willing to participate in the study, and capable of providing written informed consent prior to study registration were included. The DTI findings along with information from other investigations were used to decide the best course of management for each case. Results The study included 30 participants with a mean age of 46.0 ± 17.1 years, 63.3% and 37.7% being male and female, respectively. According to the lesion's location, the pons was found to be the most often affected area in 23.33% of cases, followed by the temporo-parietal region (13.3%) and the frontal region (13.3%). These lesions had heterogenous enhancement in 63.3% of the instances and homogeneous enhancement in 36.7% of the cases, according to a contrast study. According to their consistency, the lesions were further divided into two categories: solid lesions, which were present in 66.7% of instances, and cystic lesions, which were present in 90% of cases. Results from the diffusion tensor technique revealed that infiltration accounted for 40.0% of cases, displacement for 76.7%, and loss of white fiber tracts for 20.0%. DTI findings were significantly associated with the type of planned management and with the presence of post-management neurological deficit. Conclusion DTI played a complementary role in the assessment of tumors and can be used to improve surgical planning and therapeutic decision making. Preservation of corticospinal tracts is vital to prevent motor impairment. Availability of qualitative data with the depiction of corticospinal tracts in a three-dimensional projection and their relation with the brain tumors by DTI greatly helps in preoperative decision making and surgical approach.

Age Estimation Based on CT Chest Analysis of Ossification of the Xiphisternal Joint in a Living Population Aged 35-50 in a Tertiary Setup.

Introduction Age estimation has been an area of special interest in the medicolegal context because of its necessity in various criminal and civil cases like assaults, murders, rapes, inheritance, insurance claims, etc. While legal documents are useful in daily activities that require age identity, they cannot be relied on for criminal and civil proceedings because of being falsifiable and inaccessible to some people. Scientific methods of age determination like physical, dental, and radiological examinations are used for reliable age estimation due to their universal and non-falsifiable nature. The skeletal examination is of great importance here because the human skeleton provides many sites for age estimation in different age groups. The xiphisternal joint between the xiphoid process and the body of the sternum provides one such opportunity in participants of 35-50 years of age. The ossification in this joint proceeds gradually in approximately the third to fifth decade of life; this natural variation in the morphology of the joint can be leveraged for age estimation. Previous studies showed that the mean age of fusion varied with the ethnicity of individuals and environmental factors. Thus, it is critical to have statistical information for the concerned population to avoid errors. Also, the relation of gender with the mean age of complete fusion remained ambiguous with the previous studies. The xiphisternal joint can be studied by radiological techniques like computed tomography (CT) and plain radiographs. Radiological methods have the benefit that they can be used on both living and dead participants and are non-invasive. The present study aims at gathering data relevant for use in India (Maharashtra) and to find out the reference age group in which there is complete ossification of the xiphisternal joint in males and females.  Methods and materials This was a cross-sectional observational study in a tertiary care setup over a period of one year. High-resolution computed tomography (HRCT) was used for assessing joint fusion due to its high spatial resolution. The participants were included in the study if they were referred for HRCT chest by a physician for some pathology, did not have any trauma or lesion of the sternum and consented to the use of their information for the purpose of this study. Results The study included a total of 384 participants, out of whom 195 (50.8%) were males and 189 (49.2%) were females. The mean age of participants was 42.87 years. The mean age of complete xiphisternal joint fusion was observed to be 46.31 years (95% CI: 45.61 to 47.00) in males and 45.57 years (95% CI: 44.73 to 46.42) in females. Similarly, the mean age of participants with an unfused xiphisternal joint was observed to be 38.42 years (95% CI: 37.47 to 39.39) in males and 37.85 years (95% CI: 37.14 to 38.57) in females. There was no statistically significant difference in the age above which males and females show complete ossification of the xiphisternal joint. Conclusion The xiphisternal joint fusion can be used to determine the chronological age of an individual. It can be estimated as lesser than or equal to 45 years if the xiphisternal joint is unossified and greater than or equal to 37 years if the joint is ossified, with a 95% level of confidence.

COVID-19 associated Rhino-Orbito-Cerebral Mucormycosis: Imaging spectrum and Clinico-radiological correlation- a single Centre experience.

PURPOSE: The study aims to depict the radiological features of Cov-ROCM, depict the common routes of spread to orbits and intracranial compartment and look for an association of the risk factors with radiological severity of the disease. METHODS: 96 patients who had COVID-19 infection in the past 3 months and were diagnosed with ROCM underwent CECT PNS examinations which were assessed by two experienced radiologists. They were divided into three groups based on the intraorbital and intracranial involvement and were correlated with various risk factors. RESULTS: The incidence of bony erosions which was the commonest finding (75%) was double in Cov-ROCM than the ROCM cases of pre COVID era (33-40%). The most common route of spread to orbit was through angioinvasion(52%) with intact orbital walls; and intracranial extension was via erosion of the cribriform plate(52%). Sphenoid sinus involvement is strongly associated with intracranial and intraorbital involvement.(p-value = .0004). History of longer ICU stays and being on mechanical ventilation as a part of COVID management is associated with aggressive disease pattern(p-value = .002). Similarly, poor glycaemic control signified by raised HbA1c levels showed statistically significant correlation with severe Cov-ROCM(intraorbital/intracranial extension) (p-value = .040). CONCLUSION: Amidst the COVID pandemic, it is pertinent to look at bony erosions in case of any sinusitis, especially bony maxillary walls and the turbinates. The intraorbital compartment must be viewed thoroughly even in the absence of bony erosions due to the angioinvasive nature of these fungi. Aggressive follow-up for patients with ICU stays for COVID and for glycaemic control would help reduce the morbidity.

Plain roentgenographic and CT scan morphometric analysis of the anterior atlantodens interval (AADI) and posterior atlantodens interval (PADI) in the Indian population.

BACKGROUND: The anterior atlantodental interval (AADI) and posterior atlantodental interval (PADI) on X-ray and computed tomography (CT) studies can both be used to gauge the risk and/or presence of neurological compression. METHODS: This retrospective observational study was conducted at a tertiary care center in 116 patients with head injuries additionally warranting routine cervical X-ray and CT examinations. RESULTS: The AADI averaged 1.36 ± 0.45 mm (X-ray) and 1.393 ± 0.47 mm (CT), while the mean PADI was 18.04 ± 2.44 mm (X-ray), and 18.07 ± 2.43 mm (CT). Notably, 93.96% of the total subjects had AADI below 2 mm. Further, 6.8% of patients with PADI =/<14 mm had no neurological deficits. CONCLUSION: No significant differences were observed for X-ray versus CT studies, measuring AADI and PADI. Therefore, X-rays should continue to prove reliable for assessing craniovertebral junction anatomy in emergency settings. Of interest, the normal upper limit of AADI on sagittal CT reconstructions should now be changed to 2 mm from the previously accepted upper limit of 3 mm.