Utilization of Teleradiology by Intensive Care Units: A Cohort Study.

Aim and background: Imaging is indispensable to the diagnostic and treatment process. By facilitating access to rapid timely image interpretation, teleradiology plays a prominent role in improving access, quality of critical care, and management of the patients in intensive care units (ICU). The aim of the study is to investigate the role of teleradiology in ICU patient care and management. Materials and methods: In our study, a total of 22,081 studies of a cohort of 14,900 patients which had been transmitted from intensive care units of 80 hospitals located across the United States of America through a teleradiology reporting workflow, were interpreted by the American Board Certified Radiologists empanelled by a teleradiology service provider, located in India. Results: Among all modalities, the highest percentage of studies performed were computed tomography scan (47%) followed by radiographs (37.22%). Out of 22,081 cases under the study, 16,582 cases were reported during nighttime with a mean turnaround time (TAT) of 46.66 minutes 95% CI (46.27-47.04) while 5,499 cases were reported during daytime with a mean TAT of 44.66 minutes 95% CI (45.40-43.92). Conclusion: Setting up teleradiology service connectivity with a teleradiology service provider located in India, providing high-quality diagnostic interpretations and lower turnaround time with the ICUs in the US hospitals reduces the interval to intervention time and leads to efficient patient care management. Moreover, it also provides time advantage for US hospitals when on-site radiologists at night are unable to provide immediate coverage. Clinical significance: The ICU teleradiology service model designed in the study would greatly help overcome the shortfall of radiologists in the hospitals, provide better patient management and care by quality reporting in short turnaround time, not only during daytime but also in the night hours or on holidays when on-site radiologists are unable to provide immediate coverage. How to cite this article: Rao P, Mathur N, Kalyanpur A. Utilization of Teleradiology by Intensive Care Units: A Cohort Study. Indian J Crit Care Med 2024;28(1):20-25.

Stability and Volatility of Human Rest-Activity Rhythms: Insights from Very Long Actograms (VLAs).

Importance: Wrist-worn activity monitors provide biomarkers of health by non-obtrusively measuring the timing and amount of rest and physical activity (rest-activity rhythms, RARs). The morphology and robustness of RARs vary by age, gender, and sociodemographic factors, and are perturbed in various chronic illnesses. However, these are cross-sectionally derived associations from recordings lasting 4-10 days, providing little insights into how RARs vary with time. Objective: To describe how RAR parameters can vary or evolve with time (~months). Design Setting and Participants: 48 very long actograms ("VLAs", ≥90 days in duration) were identified from subjects enrolled in the STAGES (Stanford Technology, Analytics and Genomics in Sleep) study, a prospective cross-sectional, multi-site assessment of individuals > 13 years of age that required diagnostic polysomnography to address a sleep complaint. A single 3-year long VLA (author GD) is also described. Exposures/Intervention: None planned. Main Outcomes and Measures: For each VLA, we assessed the following parameters in 14-day windows: circadian/ultradian spectrum, pseudo-F statistic ("F"), cosinor amplitude, intradaily variability, interdaily stability, acrophase and estimates of "sleep" and non-wearing. Results: Included STAGES subjects (n = 48, 30 female) had a median age of 51, BMI of 29.4kg/m2, Epworth Sleepiness Scale score (ESS) of 10/24 and a median recording duration of 120 days. We observed marked within-subject undulations in all six RAR parameters, with many subjects displaying ultradian rhythms of activity that waxed and waned in intensity. When appraised at the group level (nomothetic), averaged RAR parameters remained remarkably stable over a ~4 month recording period. Cohort-level deficits in average RAR robustness associated with unemployment or high BMI (>29.4) also remained stable over time. Conclusions and Relevance: Through an exemplary set of months-long wrist actigraphy recordings, this study quantitatively depicts the longitudinal stability and dynamic range of human rest-activity rhythms. We propose that continuous and long-term actigraphy may have broad potential as a holistic, transdiagnostic and ecologically valid monitoring biomarker of changes in chronobiological health. Prospective recordings from willing subjects will be necessary to precisely define contexts of use.

Portal Vein Thrombosis in Patients With Cirrhosis of the Liver: Prevalence and Risk Factors.

INTRODUCTION: Chronic liver disease very often culminates into cirrhosis and its associated complications. One of the serious complications is portal venous thrombosis, which can occur due to a variety of risk factors. One significant factor contributing to portal hypertension is portal vein thrombosis (PVT). In this study, we aimed to investigate the prevalence of PVT among patients with liver cirrhosis in a tertiary hospital and identify the factors associated with this complication. METHODOLOGY: This was a cross-sectional observational study of 93 diagnosed liver cirrhosis patients treated at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) hospital in southern India between June 2020 and January 2021. A thorough evaluation of the clinical condition of the patients and associated comorbidities was done. The patients then underwent Doppler ultrasound/CECT/MRI to look for PVT and its extent. The collected data were analyzed using Statistical Product and Service Solutions (SPSS, version 24) (IBM SPSS Statistics for Windows, Armonk, NY). Comparison between two proportions was done using two two-tailed Z-test/Fisher's exact tests. RESULTS: Our study found a PVT prevalence of 17.2% in cirrhotic patients, with a higher prevalence of acute PVT than chronic PVT. Ascitic fluid infection, longer duration of cirrhosis, and increased cirrhosis severity were significantly associated with PVT development. We found no significant associations between PVT and gender, hypertension, smoking, diabetes, or the duration of alcohol intake. CONCLUSION: This study highlights the importance of early screening for PVT using Doppler USG in all patients diagnosed with cirrhosis. Additionally, anticoagulation therapy for acute PVT may be considered in patients without bleeding risks.

Protocol to evaluate hyperlipidemia in zebrafish larvae.

In this report, we describe an approach to generate a zebrafish larval model of lipid accumulation that can be used as an in vivo system to study hyperlipidemic conditions such as atherosclerosis. Furthermore, we detail steps on staining techniques, lipid estimation assays, RNA isolation, and utilization of ImageJ to evaluate larval dimensions and to explore the model in the context of hyperlipidemia. Researchers should be aware of context specificity of the proposed protocols and interpret results accordingly. For complete details on the use and execution of this protocol, please refer to Balamurugan et al., (2022).

Outcomes After Sphincter-Sparing Local Therapy for Anorectal Melanoma: 1989 to 2020.

PURPOSE: The treatment paradigm for patients with anorectal melanoma eligible for sphincter-sparing excision has evolved over time. This study examines outcomes across a 30-year era in this rare disease with poor prognosis. METHODS AND MATERIALS: This retrospective cohort study included all patients with pelvis-confined anorectal melanoma undergoing sphincter-sparing local excision and adjuvant radiation therapy (RT) at our institution between 1989 and 2020. Patterns of care and predictors of outcome were evaluated. RESULTS: Of the 108 patients included, 92 (85%) presented with clinically uninvolved nodes. For clinically node-negative patients, the sentinel lymph node biopsy rate increased from 18/43 (42%) before 2008 to 38/49 (78%) subsequently and the use of inguinal nodal RT decreased from 33/35 (94%) before 2003 to 1/57 (2%) subsequently. All clinically node-positive patients treated before 2003 received inguinal nodal RT, whereas no node-positive patient treated subsequently received this treatment. Patients treated before 2016 mostly received biochemotherapy, and those treated since 2017 mostly received immune checkpoint inhibitors. With median follow-up of 32 months, 77 patients (71%) recurred. Three-year actuarial outcomes were 84% local control, 64% nodal control, 38% distant metastasis-free survival, 30% disease-free survival, and 51% melanoma-specific survival. Ostomy-free survival at last follow-up was 95%. Factors contributing to outcome were identified. Outcomes for patients treated in the contemporary era (2017+) were not significantly better than those treated earlier. CONCLUSIONS: Sphincter-sparing surgery followed by adjuvant RT results in excellent local control and ostomy-free survival for locally resectable anorectal melanoma. Overall oncologic outcomes continue to be poor, reinforcing the need to identify more effective therapies.

Computed Tomography and Cephalometric Evaluation of Obstructive Sleep Apnea Syndrome.

To examine the changes of upper airway cross sectional area in each phase of respiration in different degrees of severity of OSAS with computed tomography and cephalometry to decide on further treatment. A Prospective study was done in the Department of Radiology and Imaging, Kasturba Medical College, Mangalore, spanning over a period from March 2017 to December 2019. 50 patients were included in the study including control group. Patients who had at least 2-3 major symptoms of sleep apnea such as snoring, daytime somnolence, and apnea were included in this study. All patients were examined and then subjected to polysomnography(PSG) and upper airway CT. Patients with apnea-hypopnea index (AHI) of < 5 on Polysomnography were included in the control group and those with AHI of > 5 were categorized in to the study group Cross-sectional area of the airway at the level of the nasopharynx, oropharynx and the hypopharynx were obtained. Standard cephalometric measurements were made on a lateral radiograph of skull/ CT scanogram. Of the 36 patients in the study group, 31 patients were males and 5 were females. In the control group of 12 patients, 8 were males and 4 females. The cross sectional area at the lower border of the nasopharynx which is also the level of the nasopharyngeal sphincter was the most affected level in OSAS (p value of < 0.0001). Mean uvular diameter in the control group was 9.6 mm and in the OSAS group it was 11.2 mm. The mean length of the soft palate was 36.4 mm in the controls, 39.5 mm in the mild/moderate OSAS and 41.2 mm in the severe OSAS group. Obstructive sleep apnea is a complex disorder characterized by apneic episodes during sleep. In this study the most common site of obstruction is nasopharyngeal sphincter and the oropharynx. Although PSG is the diagnostic test of choice, imaging plays an important role in planning surgical and conventional treatment.

Eosinophilic gastroenteritis: Clinical characteristics and management.

There is paucity of published data related to eosinophilic gastroenteritis (EGE). We aimed to study the clinical characteristics, management, and follow-up of EGE. From March 2014 to December 2018, patients with gastrointestinal (GI) symptoms suspected to have EGE were investigated. This is a retrospective study. Complete blood count, upper GI endoscopy (UGIE), and biopsy were done. Contrast-enhanced computed tomography (CECT) abdomen was done when intestinal obstruction was suspected. Laparoscopic small bowel resection or stricturoplasty and full-thickness biopsy were obtained. EGE was diagnosed if the biopsies showed eosinophilic infiltration of one or more regions of the GI tract (> 30 eosinophils per high power field [HPF]). Patients were treated with immunosuppressive therapy and if indicated surgery. Clinical response to therapy was assessed and patients were followed up for 1 year. Forty-one patients (mean age 34.8 years, median age 32, range 25-70 years, 29 males) had EGE. Upper abdominal pain was the most common symptom. Peripheral eosinophilia was present in 82.9% patients. On UGIE, duodenal lesions were observed in 75% patients. EGE was confirmed in 37 patients by endoscopic duodenal biopsies, in 2 patients by jejunal mucosal biopsies using enteroscopy, and in 2 patients by full thickness surgical biopsies. Forty-one patients were treated with oral corticosteroids inclusive of 4 patients who underwent surgery. Of the 37 patients, 6 were lost to follow-up; 31 patients were followed up for a period of 1 year. All the patients who were treated with corticosteroids responded to initial therapy. Over a follow-up period one case had frequent relapses. EGE should be suspected in patients with upper abdominal pain. Peripheral eosinophilia occurs in the majority. Tissue diagnosis showing eosinophilic infiltration is diagnostic. Oral corticosteroid therapy is highly effective and relapse is rare.

Fluoresceinated Aminohexanol Tethered Inositol Hexakisphosphate: Studies on Arabidopsis thaliana and Drosophila melanogaster and Docking with 2P1M Receptor.

Inositol hexakisphosphate (InsP6; phytic acid) is considered as the second messenger and plays a very important role in plants, animals, and human beings. It is the principal storage form of phosphorus in many plant tissues, especially in dry fruits, bran, and seeds. The resulting anion is a colorless species that plays a critical role in nutrition and is believed to cure many diseases. A fluoresceinated aminohexanol tethered inositol hexakisphosphate (III) had been synthesized earlier involving many complicated steps. We describe here a simple two-step synthesis of (III) and its characterization using different techniques such as matrix-assisted laser desorption ionization mass spectrometry, tandem mass spectrometry, and Fourier transform infrared, ultraviolet-visible, ultraviolet-fluorescence, 1H nuclear magnetic resonance (NMR), and two-dimensional NMR spectroscopies. The effect of (III) has been investigated in the model systems, Arabidopsis thaliana and Drosophila melanogaster. Using Schrodinger software, computational studies on the binding of (III) with the protein 2P1M (Auxin-receptor TIR1-adaptor ASK1 complex) has revealed strong binding propensity with this compound. These studies on the fluoresceinated tethered phytic acid could have far reaching implications on its efficacy for human health and treatment of diseases (cancer/tumor and glioblastoma) and for understanding phosphorous recycling in the environment, especially for plant systems.

"Where's My Mentor?!" Characterizing Negative Mentoring Experiences in Undergraduate Life Science Research.

Undergraduate research experiences in science, technology, engineering, and mathematics fields are championed for promoting students' personal and professional development. Mentorship is an integral part of undergraduate research, as effective mentorship maximizes the benefits undergraduates realize from participating in research. Yet almost no research examines instances in which mentoring is less effective or even problematic, even though prior research on mentoring in workplace settings suggests negative mentoring experiences are common. Here, we report the results of a qualitative study to define and characterize negative mentoring experiences of undergraduate life science researchers. Undergraduate researchers in our study reported seven major ways they experienced negative mentoring: absenteeism, abuse of power, interpersonal mismatch, lack of career support, lack of psychosocial support, misaligned expectations, and unequal treatment. They described some of these experiences as the result of absence of positive mentoring behavior and others as actively harmful behavior, both of which they perceive as detrimental to their psychosocial and career development. Our results are useful to mentors for reflecting on ways their behaviors might be perceived as harmful or unhelpful. These findings can also serve as a foundation for future research aimed at examining the prevalence and impact of negative mentoring experiences in undergraduate research.

Correlation of pharmacokinetics and brain penetration data of adult zebrafish with higher mammals including humans.

INTRODUCTION: Adult zebrafish pharmacology is evolving rapidly for creating efficacy and safety models for drug discovery. However, there is very limited research in understanding pharmacokinetics (PK) in adult zebrafish. Methods for understanding PK will help in conducting pharmacokinetic - pharmacodynamic (PK-PD) correlations and improving the quality and applicability of data obtained using zebrafish. METHODS: We conducted adult zebrafish PK and brain penetration studies on two known compounds (irinotecan and lorcaserin) with distinct PK and brain penetration properties using validated LCMS/MS method. Irinotecan was studied at a dose of 100mg/kg i.p. and levels of the parent drug and active metabolite SN-38 were measured. Loracserin was studies at a dose of 10mg/kg by two routes i.p. and p.o. RESULTS: Zebrafish PK and brain penetration profiles for both compounds were very similar to that of higher mammals including humans. Irinotecan was metabolised to SN-38 in ratios similar to ratios seen in other species and the compound had long half life with very low brain penetration in our studies. Loracasin was highly permeable in brain as compared to the exposure in blood, with long half life and high relative bioavailability, similar to other mammalian species including humans. DISCUSSION: Adult zebrafish PK studies are relatively an unexplored area of zebrafish research. The zebrafish data for key parameters of irinotecan and loracserin shows a high correlation to the data from higher species, including human. This report explores and discusses the use of adult zebrafish as a predictive PK tool for higher animal studies.

Ampullary carcinosarcoma with osteosarcomatous, small cell neuroendocrine carcinoma and conventional adenocarcinoma components; First report.

Caracinosarcomas are tumours with diverse epithelial and mesenchymal differentiation. They most commonly occur in the female reproductive organs and upper aero digestive tract. They are relatively rare in the gastrointestinal tract and affect the oesophagus most commonly. Ampullary carcinosarcomas are exceptionally rare. We report a case of ampullary carcinosarcoma in a 67-year-old male, with osteosarcomatous, small cell carcinoma and conventional adenocarcinoma components. To the best of our knowledge, this is the first reported case of its kind.

Ensembles of NLP Tools for Data Element Extraction from Clinical Notes.

Natural Language Processing (NLP) is essential for concept extraction from narrative text in electronic health records (EHR). To extract numerous and diverse concepts, such as data elements (i.e., important concepts related to a certain medical condition), a plausible solution is to combine various NLP tools into an ensemble to improve extraction performance. However, it is unclear to what extent ensembles of popular NLP tools improve the extraction of numerous and diverse concepts. Therefore, we built an NLP ensemble pipeline to synergize the strength of popular NLP tools using seven ensemble methods, and to quantify the improvement in performance achieved by ensembles in the extraction of data elements for three very different cohorts. Evaluation results show that the pipeline can improve the performance of NLP tools, but there is high variability depending on the cohort.

Cryopreservation of extracted corneal lenticules after small incision lenticule extraction for potential use in human subjects.

PURPOSE: To describe the technique of cryopreservation of corneal lenticules extracted after small incision refractive lenticule extraction (ReLEx SMILE) and initial results of femtosecond laser intrastromal lenticular implantation for hyperopia. METHODS: Lenticules were collected from patients undergoing ReLEx SMILE for the correction of myopia and subjected to a tissue processing technique and cryopreservation. These lenticules were subsequently used to treat 8 hyperopic eyes and 1 aphakic eye. A femtosecond laser was used to create a pocket into each patient's cornea, followed by implantation of a cryopreserved lenticule. The patients were monitored through follow-up examinations for a mean 155.4 days (38-310 days). RESULTS: The mean interval from storage of lenticules to removal from liquid nitrogen was 96 days (range, 19-178 days). Mean spherical equivalent of hyperopic eyes treated was +4.50 ± 1.1 diopter (D). Mean keratometry and pachymetry changed from preoperative 43.9 D and 531.6 µm to 47.4 D and 605.2 µm, respectively, postoperatively. Mean residual spherical equivalent for hyperopic eyes was +0.6 D and +4.1 D for the aphakic eye. None of the eyes showed evidence of rejection or loss of best-corrected visual acuity at the end of the follow-up period. CONCLUSIONS: The cryopreservation technique seems to be a safe method of long-term storage of refractive lenticules extracted after ReLEx SMILE for use in allogeneic human subjects. It may potentially be a safe and effective alternative to excimer laser ablation for hyperopia because of the low risks of regression, haze, flap-related complications, postoperative dry eye, and higher-order aberrations.Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: CTRI/2014/01/004331.

Osteomyelitis of the temporal bone: terminology, diagnosis, and management.

Objectives To review the terminology, clinical features, and management of temporal bone osteomyelitis. Design and Setting Prospective study in a tertiary care center from 2001 to 2008. Participants Twenty patients visiting the outpatient department diagnosed with osteomyelitis of the temporal bone. Main Outcome Measures The age, sex, clinical features, cultured organisms, surgical interventions, and classification were analyzed. Results Of the 20 cases, 2 (10%) were diagnosed as acute otitis media. Eighteen (90%) had chronic otitis media. Nineteen (95%) were classified as medial temporal bone osteomyelitis and one (5%) as lateral temporal osteomyelitis. The most common clinical features were ear discharge (100%), pain (83%), and granulations (100%). Facial nerve palsy was seen in seven cases (35%) and parotid involvement in one case. Ten patients (56%) had diabetes mellitus. The organisms isolated were Pseudomonas aeruginosa (80%) and Staphylococcus aureus (13.33%). Histopathology revealed chronic inflammation in 20 patients (100%) and osteomyelitic bony changes in 14 (70%). Surgical debridement was the most preferred modality of treatment (87%). Conclusion A new classification of temporal bone osteomyelitis has been proposed. Bacterial cultures must be performed in all patients. Antibiotic therapy is the treatment of choice. Surgical intervention is necessary in the presence of severe pain, complications, refractory cases, or the presence of bony sequestra on radiology.

Oral dosing in adult zebrafish: proof-of-concept using pharmacokinetics and pharmacological evaluation of carbamazepine.

BACKGROUND AND METHODS: We describe a method for obtaining pharmacokinetics (PK) and pharmacology data from adult zebrafish in terms of mg/kg using a novel method of oral administration. Using carbamazepine (CBZ) as a test drug, we employed dried blood spot (DBS) cards to enable drug quantification for PK; and we evaluated the pharmacological anxiolytic effect using novel tank test. RESULTS: The PK study confirmed the presence of CBZ in both blood and brain and the behavioural study showed dose dependent anxiolytic effect. The reproducibility of oral dosing was confirmed by the fact that the results obtained in both the experiments had negligible errors. CONCLUSIONS: This report enables a novel approach for optimizing the utility of zebrafish in drug discovery and drug delivery research.

Branchial anomalies: diagnosis and management.

Objective. To find out the incidence of involvement of individual arches, anatomical types of lesions, the age and sex incidence, the site and side of predilection, the common clinical features, the common investigations, treatment, and complications of the different anomalies. Setting. Academic Department of Otolaryngology, Head and Neck Surgery. Design. A 10 year retrospective study. Participants. 30 patients with clinically proven branchial anomalies including patients with bilateral disease totaling 34 lesions. Main Outcome Measures. The demographical data, clinical features, type of branchial anomalies, and the management details were recorded and analyzed. Results and Observations. The mean age of presentation was 18.67 years. Male to female sex ratio was 1.27 : 1 with a male preponderance. Of the 34 lesions, maximum incidence was of second arch anomalies (50%) followed by first arch. We had two cases each of third and fourth arch anomalies. Only 1 (3.3%) patients of the 30 presented with lesion at birth. The most common pathological type of lesions was fistula (58.82%) followed by cyst. 41.18% of the lesions occurred on the right side. All the patients underwent surgical excision. None of our patients had involvement of facial nerve in first branchial anomaly. All patients had tracts going superficial to the facial nerve. Conclusion. Confirming the extent of the tract is mandatory before any surgery as these lesions pass in relation to some of the most vital structures of the neck. Surgery should always be the treatment option. injection of dye, microscopic removal and inclusion of surrounding tissue while excising the tract leads to a decreased incidence of recurrence.