Syncope and Cardiac Arrhythmias Caused by a Paratracheal Mass.

Background: Syncope is a common complaint in clinical practice. The etiologies and mechanisms can be multiple and complex. Syncope caused by a mediastinal mass compressing the vagus nerve is rare. Case Report: We report the case of a patient who presented to the emergency department experiencing recurrent syncope. Imaging revealed a large, calcified mass in the right paratracheal region. After intracranial lesions, cardiac arrhythmias, and orthostatic hypotension were excluded, we suspected that the syncope was related to vagus nerve compression. The patient underwent surgical resection of a mediastinal mass and had complete resolution of syncopal episodes after surgery. Conclusion: This case outcome suggests that recurrent syncope could be the first symptom of an intrathoracic mass.

Evaluation of Radiological and Functional Outcome of Intra-articular Proximal Tibia Plateau Fracture Treated with Plating.

Introduction: Proximal tibial plateau fractures are one of the major problems in orthopaedic surgery and are associated with high complication rates. Intra-articular proximal tibia plateau fractures represent approximately 1% of fractures in adults. Various modalities of proximal tibial plateau fracture management have been considered, ranging from simple external fixators in impending compartment syndrome to periarticular proximal tibia plates and inter-locking nails with poller screws. Purpose of this study is to determine clinical outcomes of proximal tibial plateau fractures treated with plate. Materials and methods: We did this study of proximal tibial plateau fracture according to Schatzker's classification treated with proximal tibial periarticular plates in 53 patients prospectively admitted at the author's institute from June 2018 to May 2020 with follow-up period of 6 months. Results: In our study, the average knee score was 89.30 (ranging from 79 to 93) and functional knee score was 97.92 (ranging from 75 to 100). Fifty-one (51) patients (96.23%) showed excellent results and 2 patients (3.77%) showed good results according to Knee Society Score, which suggest that internal fixation of proximal tibia plateau fracture with plating provides better results. Out of 53 patients, 9 patients had post-operative complications. Average radiological union was seen at 14 weeks. Conclusion: Locking compression plate in proximal tibia plateau fractures act as a good biological fixation provide stable fixation, articular reduction and limb alignment even in difficult fracture situations. Fixation of proximal tibia plateau fractures with plate gives excellent to good knee society score, with satisfactory functional and radiological outcome.

Agro-morphological and genetic variability analysis in oat germplasms with special emphasis on food and feed.

The gaining attention of underutilized oat crops for both food and feed, mining of quality and yield related genes/QTLs from available germplasms of oat is need of the hour. The large family of grasses has a vast number of germplasms that could be harnessed for bio-prospecting. The selection of cross-compatible oat germplasms by molecular markers could be used for the introgression of the novel traits into the elite background of oats. The process needs a thorough study of genetic diversity to see the evolutionary relatedness among germplasms. Considering this, in the present study, the genetic diversity of 38 oat germplasms with 12 agro-morphological traits was carried out using 22 Inter Simple Sequence Repeat (ISSR) markers. We found a high level of polymorphism and 158 distinctive alleles; on average 7.18 alleles per primer, further, high-yielding genotypes were identified with the help of phenotypic data and genetic diversity was analyzed by using DNA fingerprint-based principal component analysis, UPGMA dendrogram. Among these 38 germplasms; eight were identified as superior under high grain yield (OS-424, OS-403, NDO-1101, OL-10, UPO-212, OS-405, OS-6, and OS-346) and another eight germplasms were identified as superior for the high fresh weight (for fodder purpose, NDO-711, RO-19, OL-14, OL-1760/OL-11, NDO-10, UPO-212, UPO-06-1, and RO-11-1). These results suggest that germplasms that are closely related (Cross-compatible) and have good potential for desirable traits could be used for varietal development by using marker-assisted selection.

De Quervain's tenosynovitis: a non-randomized two-armed study comparing ultrasound-guided steroid injection with surgical release.

PURPOSE: Ultrasonography is currently used for both diagnostic and therapeutic purposes in de Quervain's tenosynovitis. There is a dearth of information on how effective an ultrasound-guided (USG) steroid injection is when compared to surgical release of the first extensor compartment. Hence, we performed a non-randomized two-armed comparison study to test our hypothesis that USG guided steroid injection is equally effective as surgery. METHOD: 62 consecutive patients participated in the study with 32 of them selecting the option of USG guided injection (Set A), and the rest undergoing surgical release (Set B). We reviewed them after 3 and 6 weeks and 6 months for functional outcome using DASH, PRWE and VAS scores, recurrence, or any complications. They were further followed if they were symptomatic. RESULTS: The DASH/PRWE/VAS scores improved at the end of 6 months from 81.7/79.3/6.8 to 1.0/1.7/1.0, respectively for patients undergoing USG guided steroid injection. Similarly, for the patient undergoing surgery, the scores improved from 82.2/81.5/6.7 to 1.7/3.4/1.0, respectively. This was statistically significant in both the groups (p < 0.05) and was comparable to each other. Two patients in Set A came back with recurrence at eight and 10 months and two reported occasional pain on heavy work. Three patients had tenderness and two had numbness in Set B at the scar site. CONCLUSION: We observed that USG guided steroid injections are comparable to surgical release in terms of pain relief, functional outcome, complications.

Is balloon-assisted maxillary sinus floor augmentation before dental implant safe and promising? A systematic review and meta-analysis.

We aimed to assess the complications of minimally invasive balloon-assisted maxillary sinus floor augmentation, compared with the conventional sinus floor augmentation procedures done before placing a dental implant. A structured question was formulated and an electronic search was conducted in three databases (MEDLINE via PubMed, Google Scholar, and Scopus). A separate search of gray literature and a hand search for missing articles were also conducted. Apart from animal studies, in-vitro studies, and case reports, all other types of studies where maxillary sinus floor augmentation was done using a balloon were considered for review. Our review was registered in International Prospective Registration of Systematic Reviews (PROSPERO) under number CRD42018086770. Our search produced 73 articles. However, only eight articles were found eligible to be included in our review (seven case series and one case-control study). Quality check was done using Methodological Index for Non-Randomized Studies (MINORS). Results suggest that balloon-assisted augmentation is associated with low rates of membrane tears (9 out of 272 sinus augmentation attempts), and high follow-up bone gain levels (mean 212.91%, 95% confidence interval 158.07%-267.75%, I2 = 97.62%). Balloon-assisted augmentation seems to be safe. More clinical trials are needed to assess the advantages and disadvantages of balloon-assisted maxillary sinus floor augmentation compared with other procedures.

Evaluating cortico-cancellous ratio using virtual implant planning and its relation with immediate and long-term stability of a dental implant- A CBCT-assisted prospective observational clinical study.

BACKGROUND: Primary and long-term implant stabilities are crucial in predicting the success of dental implants. We aimed to evaluate corticocancellous ratio (CCR) around virtual implant using cone beam computed tomography (CT) and assess its relationship with immediate and long-term stability of the implants placed. MATERIALS AND METHODS: A total of 135 image records of posterior mandibular implant sites planned for dental implant were included in our study. CCR was calculated using CT images and implants were placed after stent preparation. Implant stability was calculated immediately, 4 months later, and 2 years later. RESULTS: Pearson's correlation test showed a significant correlation (P and lt; 0.001) between CCR and implant stability. ANOVA and post-hoc Tukey tests showed a significant difference in implant stability between groups with different CCRs at all follow-up timepoints. No significant difference was found between mean implant stability quotient values for low CCR at 2-year follow-up and high CCR immediately after implant placement. CONCLUSIONS: Implant stability is improved with greater CCR. Cortical bone seems to be crucial factor for immediate and long-term stability of a dental implant. Virtual planning using CT can assess implant stability. Further histological studies are required to confirm the relation between CCR and implant stability. The escalating demand of the implant treatment in the dental practice necessitates measuring the several predictors of procedure success. This study introduces a novel predictor (CCR) around virtual implant for detecting the immediate and long-term stability of a dental implant.

A quasi-ballistic drain current, charge and capacitance model with positional carrier scattering dependency valid for symmetric DG MOSFETs in nanoscale regime.

This paper presents a physically valid quasi-ballistic drain current model applicable for nanoscale symmetric Double Gate (SDG) MOSFETs. The proposed drain current model includes both diffusive and ballistic transport phenomena. The model considers the important positional carrier scattering dependency effect near the source region described in terms of transmission and reflection co-efficients related to the scattering theory. The significance of carrier transport near the bottleneck source region is illustrated where the carriers diffuse into the channel at a relatively lower velocity before accelerating ballistically. The results obtained demonstrate carrier scattering dependency at the critical layer defined near the low field source region on the drain current characteristics. The proposed model partly evolves from Natori's ballistic bulk MOSFET model that is modified accordingly to be valid for a symmetric Double Gate MOSFET in the nanoscale regime. Carrier degeneracy and Fermi-Dirac statistics are included in the work so as to justify the complete physicality of the model. The model is further extended and is shown to be continuous in terms of terminal charges and capacitances in all regions of operation. A comparative analysis is also done between the proposed quasi-ballistic model and a hypothetical complete ballistic device.

GABA Transaminase Deficiency With Survival Into Adulthood.

γ-Aminobutyric acid (GABA)-transaminase deficiency is an ultra-rare disorder of GABA metabolism that was described for decades as an early-onset epileptic encephalopathy plus movement disorder and hypersomnolence with mortality in early childhood. We report 2 affected siblings in adolescence and adulthood, both with profound developmental impairment, intractable epilepsy, movement disorder, and behavioral fluctuations. This considerably expands the phenotype and longevity of this inherited neurotransmitter disease.

Bioelectrical impedance analysis (BIA)-derived phase angle (PA) is a practical aid to nutritional assessment in hospital in-patients.

BACKGROUND: Nutritional status can be difficult to assess. Bioelectrical impedance analysis (BIA)-derived phase angle (PA), and the plasma markers citrulline and transthyretin (pre-albumin) have the potential to assist, but the protocol of fasting and resting for BIA renders the investigation impractical for routine use, especially so in populations at high risk of malnutrition. AIMS: 1 To clarify whether starving and resting are necessary for reliable measurement of PA. 2 To identify whether PA, citrulline and transthyretin correlate with nutritional status. METHODS: Eighty consenting adult in-patients were recruited. Nutritional status was determined by subjective global assessment (SGA) used as gold standard. The Malnutrition Universal Screening Tool (MUST) was used and anthropometric measurements were performed. Serum was analysed for citrulline and transthyretin. PA was measured using Bodystat 4000. The PA was considered to define malnutrition when lower than reference ranges for sex and age, and severe malnutrition if more than 2 integers below the lower limit. Anthropometric measurements were categorised according to WHO reference centiles. Ordinal logistic regression estimated the strength of association of PA, citrulline and transthyretin with SGA. PA values in the different metabolic states were compared using paired t tests. RESULTS: All 80 subjects completed the BIA and the nutritional assessments in the 3 different states; 14 declined to provide blood samples for the biochemical assays. Malnutrition was identified in 32 cases, severe malnutrition in 14 cases, the remaining 34 cases were deemed not to be malnourished. PA was strongly inversely associated with SGA (Odds Ratio [OR] per unit increase = 0.21, CI 0.12-0.37, p < 0.001). PA was not influenced by exercise (p = 0.134) or food intake (p = 0.184). Transthyretin was inversely associated with malnourished/severely malnourished states (OR = 0.98, 95% CI 0.97-0.99, p = 0.001), but had poorer predictive values than PA. There was no significant association between citrulline concentration and SGA (OR = 1.01, 95% CI 0.99-1.04, p = 0.348). CONCLUSIONS: The BIA-derived PA reliably identifies malnutrition. It is strongly associated with SGA but requires less skill and experience, and out-performs circulating transthyretin, rendering it a promising and less operator-dependent tool for assessing nutritional status in hospital patients. Our novel demonstration that fasting and bed-rest are unnecessary consolidates that position.

Advanced diffusion imaging for assessing normal white matter development in neonates and characterizing aberrant development in congenital heart disease.

Background: Elucidating developmental trajectories of white matter (WM) microstructure is critically important for understanding normal development and regional vulnerabilities in several brain disorders. Diffusion Weighted Imaging (DWI) is currently the method of choice for in-vivo white matter assessment. A majority of neonatal studies use the standard Diffusion Tensor Imaging (DTI) model although more advanced models such as the Neurite Orientation Dispersion and Density Imaging (NODDI) model and the Gaussian Mixture Model (GMM) have been used in adult population. In this study, we compare the ability of these three diffusion models to detect regional white matter maturation in typically developing control (TDC) neonates and regional abnormalities in neonates with congenital heart disease (CHD). Methods: Multiple b-value diffusion Magnetic Resonance Imaging (dMRI) data were acquired from TDC neonates (N = 16) at 38 to 47 gestational weeks (GW) and CHD neonates (N = 19) aged 37 weeks to 41 weeks. Measures calculated from the diffusion signal included not only Mean Diffusivity (MD) and Fractional Anisotropy (FA) derived from the standard DTI model, but also three advanced diffusion measures, namely, the fiber Orientation Dispersion Index (ODI), the isotropic volume fraction (Viso), and the intracellular volume fraction (Vic) derived from the NODDI model. Further, we used two novel measures from a non-parametric GMM, namely the Return-to-Origin Probability (RTOP) and Return-to-Axis Probability (RTAP), which are sensitive to axonal/cellular volume and density respectively. Using atlas-based registration, 22 white matter regions (6 projection, 4 association, and 1 callosal pathways bilaterally in each hemisphere) were selected and the mean value of all 7 measures were calculated in each region. These values were used as dependent variables, with GW as the independent variable in a linear regression model. Finally, we compared CHD and TDC groups on these measures in each ROI after removing age-related trends from both the groups. Results: Linear analysis in the TDC population revealed significant correlations with GW (age) in 12 projection pathways for MD, Vic, RTAP, and 11 pathways for RTOP. Several association pathways were also significantly correlated with GW for MD, Vic, RTAP, and RTOP. The right callosal pathway was significantly correlated with GW for Vic. Consistent with the pathophysiology of altered development in CHD, diffusion measures demonstrated differences in the association pathways involved in language systems, namely the Uncinate Fasciculus (UF), the Inferior Fronto-occipital Fasciculus (IFOF), and the Superior Longitudinal Fasciculus (SLF). Overall, the group comparison between CHD and TDC revealed lower FA, Vic, RTAP, and RTOP for CHD bilaterally in the a) UF, b) Corpus Callosum (CC), and c) Superior Fronto-Occipital Fasciculus (SFOF). Moreover, FA was lower for CHD in the a) left SLF, b) bilateral Anterior Corona Radiata (ACR) and left Retrolenticular part of the Internal Capsule (RIC). Vic was also lower for CHD in the left Posterior Limb of the Internal Capsule (PLIC). ODI was higher for CHD in the left CC. RTAP was lower for CHD in the left IFOF, while RTOP was lower in CHD in the: a) left ACR, b) left IFOF and c) right Anterior Limb of the Internal Capsule (ALIC). Conclusion: In this study, all three methods revealed the expected changes in the WM regions during the early postnatal weeks; however, GMM outperformed DTI and NODDI as it showed significantly larger effect sizes while detecting differences between the TDC and CHD neonates. Future studies based on a larger sample are needed to confirm these results and to explore clinical correlates.

Combined external beam radiotherapy and vaginal brachytherapy versus vaginal brachytherapy in stage I, intermediate- and high-risk cases of endometrium carcinoma.

PURPOSE: Randomized trials on the effect of external beam radiotherapy (EBRT) with or without vaginal brachytherapy (VBT) for endometrial carcinoma are very few. In view of this, the current study was conducted with the hypothesizes: whether the escalated dose of 26 Gy (VBT alone) in comparison with various major international trials (PORTEC-2) has any difference in rates of disease-free and overall survival with fewer adverse effects in low resource setting like India. MATERIAL AND METHODS: An open-labeled, non-inferiority, randomized control trial was undertaken at a regional cancer center among patients with stage IA or IB high-intermediate risk endometrial carcinoma. A total of 50 patients were divided equally among two arms of combined EBRT with VBT (arm I) and VBT alone (arm II). A dose of 50-50.4 Gy in 25-28 fractions of EBRT with 2 fractions of VBT 6.5 Gy each were delivered to patients in arm I and 4 fractions of VBT 6.5 Gy each to patients in arm II, and were followed up for 60 months. RESULTS: During the median follow-up of 36.5 months, two patients developed loco-regional recurrence in arm II, three (arm II), and one (arm I) developed distant metastasis. The 5-year survival rates for arms I and II were 96.0% vs. 92.0% overall, and 88.0% vs. 84.0% disease-free, respectively, and were not found to be statistically significantly different. Dermatological, gastro-intestinal toxicities, and cystitis were lower in the VBT group compared to combined group. CONCLUSIONS: VBT alone is as effective as EBRT+VBT in ensuring loco-regional control and achieving comparable survival rates, with fewer toxic effects for patients with stage I intermediate- and high-risk endometrial carcinoma. The dose escalation did not make a difference in the survival rates and was like in the other major trials (PORTEC-2).

Occult lawn mower projectile injury presenting with hemoptysis.

We present the case of a 72-year-old man with hemoptysis after a thoracic projectile injury, which occurred while mowing the lawn. Chest radiograph followed by a computed tomography angiogram revealed a metallic foreign body in the right middle lobe of the lung. The patient underwent a right anterolateral thoracotomy where the object was successfully retrieved. The patient had an uneventful postoperative recovery.

Content Validation and Evaluation of an Endovascular Teamwork Assessment Tool.

OBJECTIVE/BACKGROUND: To modify, content validate, and evaluate a teamwork assessment tool for use in endovascular surgery. METHODS: A multistage, multimethod study was conducted. Stage 1 included expert review and modification of the existing Observational Teamwork Assessment for Surgery (OTAS) tool. Stage 2 included identification of additional exemplar behaviours contributing to effective teamwork and enhanced patient safety in endovascular surgery (using real-time observation, focus groups, and semistructured interviews of multidisciplinary teams). Stage 3 included content validation of exemplar behaviours using expert consensus according to established psychometric recommendations and evaluation of structure, content, feasibility, and usability of the Endovascular Observational Teamwork Assessment Tool (Endo-OTAS) by an expert multidisciplinary panel. Stage 4 included final team expert review of exemplars. RESULTS: OTAS core team behaviours were maintained (communication, coordination, cooperation, leadership team monitoring). Of the 114 OTAS behavioural exemplars, 19 were modified, four removed, and 39 additional endovascular-specific behaviours identified. Content validation of these 153 exemplar behaviours showed that 113/153 (73.9%) reached the predetermined Item-Content Validity Index rating for teamwork and/or patient safety. After expert team review, 140/153 (91.5%) exemplars were deemed to warrant inclusion in the tool. More than 90% of the expert panel agreed that Endo-OTAS is an appropriate teamwork assessment tool with observable behaviours. Some concerns were noted about the time required to conduct observations and provide performance feedback. CONCLUSION: Endo-OTAS is a novel teamwork assessment tool, with evidence for content validity and relevance to endovascular teams. Endo-OTAS enables systematic objective assessment of the quality of team performance during endovascular procedures.

Acquired post-traumatic aortic coarctation presenting as new-onset congestive heart failure: treatment with endovascular repair.

Acquired coarctation of the thoracic aorta is a rare phenomenon in adults. The etiology is often idiopathic, but severe stenosis can develop from prior surgery, blunt thoracic aortic injuries, or severe atherosclerotic/atheroembolic disease. Common symptomatic presentations include refractory upper extremity hypertension and new-onset congestive heart failure. We present the case of a 52-year-old man who developed acquired thoracic aortic coarctation 30 years after a blunt trauma and deceleration injuries to the aorta requiring open surgical aortic repair. He presented with poorly controlled hypertension and new-onset heart failure and was treated surgically with endovascular repair.

Single Stage Repair of Aortic Coarctation and Coronary Artery Bypass Grafting in a 55-Year- Old-Man Presenting with Pulmonary Edema.

Coarctation of the aorta, virtually always a congenital malformation, is characterized by localized aortic narrowing, usually in the arch opposite to the ductus arteriosus and just distal to the left subclavian artery. The condition occasionally goes undiagnosed until adulthood. We report a case of a 55-year-old man who presented with uncontrolled hypertension, pulmonary edema, and non-ST-segment elevation myocardial infarction due to multi-vessel coronary artery disease. He underwent successful simultaneous coronary artery bypass grafting and coarctation repair using an ascending-to-descending aortic bypass graft.

Diffraction of orbital angular momentum carrying optical beams by a circular aperture.

Far field diffraction of Laguerre-Gauss vortex (LGV) beams of different angular momentum index by a circular aperture placed at different locations with respect to incident beam waist is studied experimentally. The experiments reveal a surprisingly simple structure for the diffraction pattern and its dependence on the orbital angular momentum index of the incident beam when the aperture size is small compared to the beam radius.

Blended distance education program for junior doctors working in rural hospitals in India.

CONTEXT: Distance learning, supported with supervised clinical work, has been successful in helping doctors located in remote rural areas to practice effectively. Graduates of Christian Medical College (CMC), Vellore, India, have a 2-year service obligation to work in small hospitals mainly located in rural areas. The Fellowship in Secondary Hospital Medicine (FSHM) program is a year-long blended on-site and distance learning program, designed by CMC to support and provide education opportunities for its recent graduates working in small hospitals in rural areas. The FSHM program was designed to help junior doctors develop the knowledge and skills to practice effectively in rural hospitals. ISSUES: The FSHM program consists of 15 paper-based distance learning modules focused on helping to develop knowledge to practice in rural hospitals; three contact sessions at CMC, which focused on developing the necessary skills; project work focused on improving local health services; and networking between peers and with faculty. Two years after implementation of the FSHM program in 2007, the vast majority of students (81%) and faculty (80%) rated the distance learning modules as very good or excellent in helping students develop the knowledge to practice in secondary hospitals. Also, most of the students (88%) and faculty (87%) rated the contact sessions as good or very good in helping students to apply what they had learned in secondary hospitals. Focus group discussions revealed that all of the program participants recognized that the distance learning modules and contact sessions helped them in providing patient care in rural hospitals. LESSONS LEARNED: Well-designed distance learning modules, supported with contact sessions by medical school faculty members, help junior doctors to practice effectively in rural hospitals and reduce their isolation.

Isolation and characterization of methane utilizing bacteria from wetland paddy ecosystem.

Methylotrophic bacteria which are known to utilize C1 compounds including methane. Research during past few decades increased the interest in finding out novel genera of methane degrading bacteria to efficiently utilize methane to decrease global warming effect. Moreover, evaluation of certain known plant growth promoting strains for their methane degrading potential may open up a new direction for multiple utility of such cultures. In this study, efficient methylotrophic cultures were isolated from wetland paddy fields of Gujarat. From the overall morphological, biochemical and molecular characterization studies, the isolates were identified and designated as Bacillus aerius AAU M 8; Rhizobium sp. AAU M 10; B. subtilis AAU M 14; Paenibacillus illinoisensis AAU M 17 and B. megaterium AAU M 29. Gene specific PCR analysis of the isolates, P. illinoisensis, B. aerius, Rhizobium sp. and B. subtilis showed presence of pmoA gene encoding α subunit particulate methane monooxygenase cluster. B. megaterium, P. illinoisensis, Rhizobium sp. and Methylobacterium extrorquens showed presence of mmoX gene encoding α subunit of the hydroxylase component of the soluble methane monooxygenase cluster. P. illinoisensis and Rhizobium sp. showed presence mxaF gene encoding α subunit region of methanol dehydrogenase gene cluster showing that both isolates are efficient utilizers of methane. To the best of our knowledge, this is the first time report showing presence of methane degradation enzymes and genes within the known PGPB group of organisms from wet land paddy agro-ecosystem, which is considered as one of the leading methane producer.