Double Level Non-Contiguous Traumatic Lumbar Disc Herniation Presenting With Cauda Equina Syndrome: A Case Report and Literature Review.

CASE: A 52-year-old man presented with cauda equina syndrome after a motorcycle accident. Magnetic resonance imaging revealed traumatic disc herniation, at L2-L3 and L5-S1 levels without bony injury. He was managed successfully by wide laminectomy and microdiscectomy at both levels with complete neurological recovery at 2-month follow-up. CONCLUSION: With a reported incidence of 0.4%, traumatic disc herniation in the lumbar region is an uncommon occurrence that may resemble a spinal epidural hematoma in acute trauma. Although MRI may not reliably differentiate spinal epidural hematoma from disc herniation, urgent surgical intervention may be required in profound neurological deficits.

The disc-endplate-bone-marrow complex classification: progress in our understanding of Modic vertebral endplate changes and their clinical relevance.

BACKGROUND CONTEXT: The disc, endplate (EP), and bone marrow region of the spine form a single anatomical and functional interdependent unit; isolated degeneration of any one structure is rare. Modic changes (MC), however, are restricted to the subchondral bone alone and based on only T1 and T2 sequences of MRI. This results in poor reliability in differentiating fat from edema and hence may give a false impression of disease inactivity. PURPOSE: To study the changes in disc, endplate, and bone marrow as a whole in degeneration and propose a classification based on the activity status of this complex with the addition of STIR MRI sequences. STUDY DESIGN: Observational cohort. PATIENT SAMPLE: Patients with isolated brain, cervical, or thoracic spine injury and patients with low back pain (LBP) who underwent MRI formed the control and study groups, respectively. OUTCOME MEASURES: Demographic data, the prevalence of MC and disc-endplate-bone marrow classification (DEBC) changes, EPs undergoing reclassification based on DEBC, and comparison of the prevalence of MC, DEBC, H+modifier and DEBC with H+concordance between control and LBP group. The study determined the risk of LBP patients undergoing surgery as well as the incidence of postoperative infection based on DEBC changes. Significance was calculated by binomial test and chi-square test with the effect size of 0.3 to 0.5. Prevalence and association of outcome were calculated by Altman's odds ratio with the 95% CI and the scoring of z statistics. Logistic expression was plotted for independent variables associated with each class of both Modic and DEBC against dependent variables surgery and nonsurgery. METHODS: Lumbar segments in both groups were assessed for MC types. The DEBC classification was developed with the addition of STIR images and studying the interdependent complex as a whole: type-A: acute inflammation; type-B: chronic persistence; type-C: latent and type-D: inactive. Modifier H+ was added if there was disc herniation. The classification was compared with MC and correlated to clinical outcomes. RESULTS: A total of 3,560 EPs of 445 controls and 8,680 EPs in 1,085 patients with LBP were assessed. Four nonMC, 560 MC-II, and 22 MC-III EPs were found to have previously undetected edema in STIR (n=542) or hyperintensity in discs (n=44) needing reclassification. The formerly undescribed type-B of DEBC, representing a chronic persistent activity state was the most common (51.8%) type. The difference between the control and LBP of H+(12% vs 28.8%) and its co-occurrence with DEBC type 1.1% vs 23.3%) was significant (p<.0001). The odds ratio for the need for surgery was highest (OR=5.2) when H+ and DEBC type change co-occurred. Postoperative deep infection (as determined by CDC criteria) was 0.47% in nonDEBC, compared with 2.4% in patients with DEBC (p=.002), with maximum occurrence in type-B. CONCLUSION: Classification based on the classic MC was found to need a reclassification in 586 EPs showing the shortcomings of results of previous studies. Considering the DEBC allowed better classification and better predictability for the need for surgical intervention and incidence of postoperative infection rate than MC.

Navigating the Pandemic: An Exploration of Medical Practitioners' Preparedness, Concerns, Adaptations, and Practices During the COVID-19 Epidemic in India.

Introduction The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, has had profound health and societal impacts, and healthcare providers from diverse backgrounds had to continuously adapt and update to manage patient care, prevent morbidity-mortality, and minimize transmission of the infection. Methodology A cross-sectional survey was conducted among 218 doctors in western India. A structured questionnaire was used to gather data on demographic characteristics, patient consultations, infection prevention practices, COVID-19 diagnosis, management, vaccination attitudes, and healthcare program disruptions. Multistage probability sampling was undertaken to select 161 (64%) private and 57 (26%) public sector doctors from the list of clinics and hospitals reporting COVID-19 cases in the urban municipal corporation area of South Gujarat. Private sector doctors were contacted through the network of public administrative staff and caregivers of their area. They were provided the choice of date, time, and mode (telephonically, face to face, or online) of interview. Descriptive measures of central tendency and variation were calculated. Inferential statistics was applied to test the significance of the difference between sub-groups. For ratio and interval variables, t-test (for two groups) and ANOVA (for more than two groups) were applied while for nominal and ordinal variables, chi-square and appropriate tests were applied. Results The mean age of the 218 doctors included in the study was 43.6 ± 11.1 years while the mean duration of practice was 16.9 ±10.8 years. During the pandemic, patients' consultation frequencies decreased at the clinics while telephonic and residential consultancies increased, which was statistically significant (P=0.000). Social distancing (n= 187; 85%), isolation (n=157; 72%), and consultation reduction (n=65; 30%) were adopted by doctors. Both public and private doctors preferred government-recognized COVID-19 centers for testing (n=167; 76.7%) and reverse transcriptase-polymerase chain reaction (RT-PCR) as the standard diagnostic test (n=196; 90%). A combination of antipyretics, favipiravir, and antibiotics was used to manage symptomatic cases. Concerns and emotional stress for personal and family safety were prominent among this group of frontline medical doctors (94%). Delivery of healthcare programs for chronic conditions like hypertension and tuberculosis was negatively affected (n=102; 47%). Despite these challenges, doctors managed cases and advised vaccination to control the pandemic. Conclusion This study among over 200 qualified medical practitioners during the pandemic attempts to fill gaps in COVID-19 management, prevention, and safety measures. To the best of our knowledge, this is one of the few studies providing genuine insights into the practice of private doctors with a large sample size. Findings show the established treatment, prophylaxis, and vaccination protocols among private and public practitioners. It highlights the need for adaptable healthcare strategies and collaboration between public and private sectors for managing future global health emergencies.

Quantifying climatic and socioeconomic drivers of urban malaria in Surat, India: a statistical spatiotemporal modelling study.

BACKGROUND: Cities are becoming increasingly important habitats for mosquito vectors of disease. The pronounced heterogeneity of urban landscapes challenges our understanding of the effects of climate and socioeconomic factors on mosquito-borne disease dynamics at different spatiotemporal scales. Here, we quantify the impact of climatic and socioeconomic factors on urban malaria risk, using an extensive dataset in both space and time for reported Plasmodium falciparum cases in the city of Surat, northwest India. METHODS: We analysed 10 years of monthly P falciparum cases resolved at three nested spatial resolutions (seven zones, 32 units, and 478 worker units) with a Bayesian hierarchical mixed model that incorporates the effects of population density, poverty, relative humidity, and temperature, in addition to random effects (structured and unstructured). To reduce dimensionality and avoid correlation of covariates, socioeconomic variables from survey data were summarised into main axes of variation using principal component analysis. With model selection, we identified the main drivers of spatiotemporal variation in malaria incidence rates at each of the three spatial resolutions. We also compared observations to model-fitted cases by quantifying the percentage of predictions within five discrete levels of malaria risk. FINDINGS: The spatial variation of urban malaria cases was stationary over time, whereby locations with high and low yearly cases remained largely consistent across years. Local socioeconomic variation could be summarised with three principal components accounting for approximately 80% of the variance. The model that incorporated local temperature and relative humidity together with two of these principal components, largely representing population density and poverty, best explained monthly malaria patterns in models formulated at the three different spatial scales. As model resolution increased, the effect size of humidity decreased, whereas those of temperature and the principal component associated with population density increased. Model predictions accurately captured aggregated total monthly cases for the city; in space-time, they more closely matched observations at the intermediate scale, with around 57% of units estimated to fall in the observed category on average across years. The mean absolute error was lower at the intermediate level, showing that this is the best aggregation level to predict the space-time dynamics of malaria incidence rates across the city with the selected model. INTERPRETATION: This statistical modelling framework provides a basis for development of a climate-driven early warning system for urban malaria for the units of Surat, including spatially explicit prediction of malaria risk several weeks to months in advance. Results indicate environmental and socioeconomic covariates for which further measurement at high resolution should lead to model improvement. Advanced warning combined with local surveillance and knowledge of disease hotspots within the city could inform targeted intervention as part of urban malaria elimination efforts. FUNDING: US National Institutes of Health.

Surgical Approach to Cervical Fractures in Ankylosing Spondylitis Patients: Rationale and Surgical Strategy.

BACKGROUND: Current literature lacks objective criteria to determine surgical management in patients with ankylosing spondylitis who sustain cervical fractures. The purpose of our study was to analyze the determinants for stratifying surgical approach, evaluate the outcome in patients, and postulate a management strategy. METHODS: This was a retrospective study of patients with ankylosing spondylitis who underwent surgery for cervical spine injury with a minimum follow-up of 2 years. Neurological recovery, fracture pattern including translation and angulation, surgical duration, blood loss, and postoperative complications were recorded, and a comparative analysis of these factors with anterior, posterior, and combined surgical approaches was performed. RESULTS: The study included 43 men with a mean age of 57 years; 49% underwent anterior-only stabilization, 16% underwent posterior-only stabilization, and 35% underwent combined anteroposterior stabilization. Mean operative time was significantly lower in anterior-only (81.4 minutes; P < 0.05) and posterior-only (124 minutes; P < 0.05) approaches compared with combined approach (266.6 minutes). Mean blood loss was significantly lower in anterior-only (87.5 mL, P < 0.05) approach compared with posterior-only (714.7 mL) and combined (912.7 mL) approaches. Mean translation was 1.8 mm, 1.7 mm, and 3.7 mm in anterior, posterior, and combined approaches (P < 0.05), respectively. CONCLUSIONS: Our study provides insights into management of cervical spine fractures in ankylosing spondylitis patients. A fracture displacement ≤2 mm may be successfully managed by an anterior approach, while the posterior approach may be beneficial in similar fractures warranting instrumentation extending to the thoracic spine. All other fractures warrant a combined surgical approach.

Evaluation of vaccine cold chain in urban health centers of municipal corporation of surat city, Western India.

BACKGROUND: The success of immunization depends highly on the level of cold chain maintenance. The aim of the study was to assess the condition of cold chain equipment, practices adopted for cold chain maintenance and knowledge of the vaccinators. METHODS: It was a cross-sectional study conducted in 20 UHCs of Surat Municipal Corporation (SMC). Cold chain equipment were observed with regards to their condition, along with the practices adopted by vaccinators for cold chain maintenance. A pre-designed and pre-tested questionnaire was used to interview the vaccinators regarding their knowledge and awareness regarding cold chain practices, management and handling. Data were entered and analyzed using Epi Info v 3.5.1. Simple proportions were calculated. RESULTS: Absence of separate stabilizer for deep freezers and ILRs (85%), ill-maintained temperature-record register, lack of criss-cross pattern of ice packs in deep freezer (65%), presence of things other than ice packs in deep freezer (10%) and things other than vaccines in ILR (10%) indicate poor cold chain maintenance. In addition to this, expired vaccines in ILR (5%), vaccines in the "unusable" stages of VVM (15%), lack of emergency contact number nearby in case of cold chain failure (85%), lack of inverter (85%), lack of generator (85%) and failure to note time of reconstitution on the vaccine vial at the time of vaccination (25%) indicate poor cold chain practices. Lack of knowledge of defrosting of ILR and deep freezer (45%), lack of knowledge about Shake test (40%), lack of knowledge of temperature range to be maintained in deep freezer (70%) and in ILR (15%) indicate poor knowledge of vaccinators. CONCLUSION: Cold chain maintenance and practices need improvement. Knowledge of vaccinators was overall unsatisfactory.

Competing hydrogen-bond acceptors in ethylenediammonium oxotrithiotungstate(VI).

The structure of the title compound, (C(2)H(10)N(2))[WOS(3)], consists of ethylenediammonium dications and tetrahedral [WOS(3)](2-) dianions, which are linked with the aid of four varieties of hydrogen bond, namely N-H...O, N-H...S, C-H...O and C-H...S. The strength and number of these hydrogen bonds affect the W-O and W-S bond distances.

Bis(isopropyl-ammonium) tetra-sulfido-molybdate(VI).

The title compound, (C(3)H(10)N)(2)[MoS(4)], was synthesized by passing a rapid stream of H(2)S into an aqueous isopropyl-amine solution of molybdic acid. The title compound is isotypic with the corresponding W analogue (C(3)H(10)N)(2)[WS(4)]; its structure consists of a slightly distorted tetra-hedral [MoS(4)](2-) dianion and two crystallographically independent isopropyl-ammonium cations, with all atoms located in general positions. The cations and anion are linked by weak N-H⋯S and C-H⋯S inter-actions, the strength and number of which can explain the observed Mo-S bond distances.