Air Nozzle Injury: Barotrauma Resulted From an Industrial Accident.

Industrial accidents involving compressed air can lead to significant colonic injuries, ranging from minor tears to complete perforations. This study investigates a case of colonic barotrauma in a 40-year-old male oil refinery worker who suffered symptoms of lower abdominal discomfort, distension, and tenderness following the application of compressed air to his anus. Diagnostic tests, including blood count, abdominal X-ray, and ultrasonography, indicated fecal impaction, dilated bowel loops, and free gas under the diaphragm. An exploratory laparotomy revealed a 4 cm x 2 cm hole in the colon at the hepatic flexure. There were also small breaks in the mucosa at the junction of the recto-sigmoid. We surgically repaired the perforation with primary closure, metrogyl lavage, and the placement of an intra-abdominal pelvic drain. Two weeks later, the patient recovered without any complications and was discharged. This case report highlights the severe risks of non-medical compressed air exposure, as well as the critical need for immediate surgical intervention and preventive safety measures in industrial settings.

Lower Extremity Muscle Tendon Interaction Around Knee During Gait Among Adolescent Children with Cerebral Palsy with Varying Crouch Angle.

Background: Optimal management and surgical planning of severe bony deformities and muscle tendon unit contractures demands comprehensive evaluation of all structures including the dynamic muscle tendon length of all muscles around the joint during gait. Objectives: Present study aimed to explore dynamic muscle-tendon length for all muscles around the knee joint along with pelvis, hip, and ankle joint kinematics among adolescent children with varying crouch angle. Methods: Muscle-tendon length of 29 adolescent children with cerebral palsy with varying crouch angles was computed using a full-body musculo-skeletal model and expressed as a percentage of muscle-tendon length during walking compared to resting condition. Results: Children with knee flexion angle greater than 25° demonstrated lower anterior pelvic tilt and 11% greater muscle-tendon length of semimembranosus and biceps femoris during stance phase of gait compared to children with knee flexion angle less than 25° and typically developing children (p < 0.01). Conclusions: The findings of present study reported that routine bedside clinical evaluation in adolescent children with knee flexion angle greater than 25° revealed moderate shortening of hamstring muscle in supine position. Whereas instrumented objective evaluation of gait demonstrated lengthened hamstring muscle and reduced hip extension and relatively lower anterior pelvic tilt. Therefore, it may be valuable to add objective assessment of dynamic muscle-tendon length to kinematics of all lower-extremity joint motion during gait, in order to understand the muscle-joint interactions; particularly in children with severe crouch and plan specific, tailor-made surgical and non-surgical interventions.

Are Generative Pretrained Transformer 4 Responses to Developmental Dysplasia of the Hip Clinical Scenarios Universal? An International Review.

OBJECTIVE: There is increasing interest in applying artificial intelligence chatbots like generative pretrained transformer 4 (GPT-4) in the medical field. This study aimed to explore the universality of GPT-4 responses to simulated clinical scenarios of developmental dysplasia of the hip (DDH) across diverse global settings. METHODS: Seventeen international experts with more than 15 years of experience in pediatric orthopaedics were selected for the evaluation panel. Eight simulated DDH clinical scenarios were created, covering 4 key areas: (1) initial evaluation and diagnosis, (2) initial examination and treatment, (3) nursing care and follow-up, and (4) prognosis and rehabilitation planning. Each scenario was completed independently in a new GPT-4 session. Interrater reliability was assessed using Fleiss kappa, and the quality, relevance, and applicability of GPT-4 responses were analyzed using median scores and interquartile ranges. Following scoring, experts met in ZOOM sessions to generate Regional Consensus Assessment Scores, which were intended to represent a consistent regional assessment of the use of the GPT-4 in pediatric orthopaedic care. RESULTS: GPT-4's responses to the 8 clinical DDH scenarios received performance scores ranging from 44.3% to 98.9% of the 88-point maximum. The Fleiss kappa statistic of 0.113 ( P = 0.001) indicated low agreement among experts in their ratings. When assessing the responses' quality, relevance, and applicability, the median scores were 3, with interquartile ranges of 3 to 4, 3 to 4, and 2 to 3, respectively. Significant differences were noted in the prognosis and rehabilitation domain scores ( P < 0.05 for all). Regional consensus scores were 75 for Africa, 74 for Asia, 73 for India, 80 for Europe, and 65 for North America, with the Kruskal-Wallis test highlighting significant disparities between these regions ( P = 0.034). CONCLUSIONS: This study demonstrates the promise of GPT-4 in pediatric orthopaedic care, particularly in supporting preliminary DDH assessments and guiding treatment strategies for specialist care. However, effective integration of GPT-4 into clinical practice will require adaptation to specific regional health care contexts, highlighting the importance of a nuanced approach to health technology adaptation. LEVEL OF EVIDENCE: Level IV.

Lengthening in congenital posteromedial bowing of tibia: a follow-up series at skeletal maturity.

PURPOSE: Congenital posteromedial bowing (CPMB) of tibia is a rare, usually self-resolving condition that is present at birth. The data on the long-term outcome of lengthening, choice of fixator, outcome in early and late age groups, and complications is sparse, hence the need for this study. METHODS: This retrospective study included 93 patients with 94 affected legs from 1991 to 2023. The patients were categorized into early (under 10 years) and late (10 years or above) intervention groups. Eighteen patients with nineteen lengthening episodes who attained skeletal maturity made the basis of this study and will be discussed in detail. RESULTS: The outcome for the lengthening group at maturity was satisfactory, with 5.53 cm of average length gained per lengthening episode, a mean LLD of 0.31 cm at final follow-up, a mean age of 23.63 years (range 14-38 years), and an average follow-up of 12.51 years (range 3-28 years) post-lengthening, but the procedure was associated with difficulties like ankle stiffness, tibial valgus, pin tract infections, and fractures through regenerate. CONCLUSION: This study represents a large single-centre series on CPMB. We recommend that surgery for lengthening should be done at an older age, close to skeletal maturity, wherever possible to reduce the risk of repeat lengthening procedures. Based on our experience, we recommend the use of a circular fixator. Uniplanar distractors should have an adequate number and spread of Schanz screws in each segment to reduce the risk of valgus malalignment of distracting segments of bone.

Spinal dysraphism in congenital scoliosis and kyphosis: a retrospective analysis in an Indian population.

PURPOSE: Early recognition is crucial for occult spinal dysraphism associated with congenital spinal deformities. There is limited literature available on its occurrence in congenital scoliosis and kyphosis in the Indian population. METHODS: Our study involved a retrospective review of 247 children who presented at a single centre. We analyzed their demographics and clinical and radiological findings, which included the type of deformity, its location, vertebral anomaly, Cobb angle, and MRI findings. The deformities were categorized as congenital scoliosis or congenital kyphosis with failure of formation, failure of segmentation, or both. RESULTS: A total of 247 cases were examined (congenital scoliosis-229, congenital kyphosis-18). The average age was seven years (range 0.8 to 19 years, SD 4.6). The mean Cobb angle at presentation in the congenital scoliosis group was 49.4° (range 8 to 145°, SD 23.77) for those with abnormal MRI and 42.45° (range 5 to 97°, SD 20.09) for those with normal MRI. For the congenital kyphosis group, the mean K angle at presentation was 47.7° (range 14 to 110°, SD 33.33) for those with abnormal MRI and 47.36° (range 15 to 70°, SD 16.63) for those with normal MRI. Abnormal MRI results were observed in 130 of the patients (congenital scoliosis-53.7%, congenital kyphosis-38.8%). The highest incidence of abnormal MRI findings was observed in the failure of segmentation (66.6%) and mixed (65%) types. Deformities in the dorsal region had the highest incidence (61.9%). The most common dysraphism instances were diastematomyelia and tethered cord. There was a significant correlation between type of deformity and presence of dysraphism. CONCLUSION: This is the largest case series of congenital scoliosis and kyphosis reported from India. We found a high incidence of occult spinal dysraphism as compared to other published series. Occult spinal dysraphism is more common in the thoracic region. Diastematomyelia followed by tethered cord was the most common anomaly observed. We recommend MRI screening of whole spine and craniovertebral junction.

Causes of late-presenting developmental dislocation of the hip beyond 12 months of age: A pilot study.

Background & objectives: Developmental dysplasia of the hip (DDH), when detected early, can usually be managed effectively by simple methods. A delayed diagnosis often makes it a complex condition to treat. Late presentation of DDH is fairly common in developing countries, and there is scarcity of literature regarding the epidemiology and reason for late presentation. Through this study, we attempted to identify the reasons for late presentation of DDH in children more than 12 months of age. Methods: Fifty four children with typical DDH and frank dislocation of hip in whom treatment was delayed for 12 months or more were included. Parents were interviewed with a pre-structured questionnaire and data were collected for analysis with Microsoft Excel 2016 and SPSS version 26. Results: Diagnostic delay was the most common reason for late presentation and was observed in 52 children (96.2%). The mean age at diagnosis was 24.7 months. The mean age at treatment was 37.3 months with a mean delay of 12.5 months from diagnosis and 22.1 months from initial suspicion. Physician-related factors contributed 55.3 per cent, while family and social issues accounted for 44.7 per cent of overall reasons for diagnostic and treatment delays. Interpretation & conclusions: Late presentation of DDH in walking age is common. Physician- and family-related factors accounted for most of these cases. Failure or inadequate hip screening at birth by the attending physician is a common reason for late diagnosis. The family members were unaware about the disorder and developed suspicion once child started walking with an abnormal gait.

Regional anesthesia and analgesia in patients with spastic cerebral palsy undergoing orthopedic surgery: a historical cohort study.

PURPOSE: We sought to examine the incidence of severe postoperative pain in patients with cerebral palsy (CP) in the first 48 hr after surgery performed under combined regional and general anesthesia and its association with patient and surgical factors. METHODS: In a historical cohort study, we reviewed the electronic records of 452 patients with spastic CP who underwent orthopedic surgeries of the upper and lower extremities from April 2016 to February 2020. Collected data included patient characteristics, American Society of Anesthesiologists Physical Status, details of anesthesia and surgery, types of regional anesthesia applied, success rate of anesthesia, incidence of severe pain, and adverse events. RESULTS: We analyzed data from 440 patients; 404 patients underwent lower extremity surgery, 20 upper extremity surgery, and 15 both, and one patient required stem cell injection. All patients received general anesthesia before block performance. Single-injection neuraxial anesthesia was performed in 241 (54.8%) patients, brachial plexus block in 27 (6.1%) patients, and femoral/sciatic nerve blocks in 17 (3.9%) patients. Continuous neuraxial, brachial plexus, and femoral/sciatic nerve blocks were performed in 149 (33.9%), four (0.9%), and seven (1.6%) of the patients, respectively. Major and complex major surgeries were performed in 161 (36.6%) and 72 (16.4%) patients, respectively and continuous catheters were inserted in 50.3% of patients undergoing major surgery and in 91.7% of patients undergoing complex major surgery. Severe pain was reported by the caregivers of 68 (15.5%) patients who received nonopioid analgesic interventions. CONCLUSION: Despite the use of regional anesthesia, approximately 15% of patients with spastic CP undergoing orthopedic surgery for spastic cerebral palsy experienced severe pain that responded to treatment adjustments. STUDY REGISTRATION: CTRI.nic.in (027002); registered 5 August 2020.

RéSUMé: OBJECTIF: Nous avons cherché à examiner l'incidence de la douleur postopératoire sévère chez les personnes atteintes de paralysie cérébrale (PC) au cours des 48 premières heures suivant une chirurgie réalisée sous anesthésie régionale et générale combinée et son association avec les facteurs liés aux patient·es et les facteurs chirurgicaux. MéTHODE: Dans une étude de cohorte historique, nous avons examiné les dossiers électroniques de 452 personnes atteintes de PC spastique ayant bénéficié de chirurgies orthopédiques des membres supérieurs et inférieurs d'avril 2016 à février 2020. Les données recueillies comprenaient les caractéristiques des patient·es, le statut physique selon l'American Society of Anesthesiologists, les détails de l'anesthésie et de la chirurgie, les types d'anesthésie régionale appliqués, le taux de réussite de l'anesthésie, l'incidence de la douleur intense et les événements indésirables. RéSULTATS: Nous avons analysé les données de 440 patient·es; 404 ont bénéficié d'une chirurgie des membres inférieurs, 20 d'une chirurgie des membres supérieurs et 15 des deux, et une personne a nécessité une injection de cellules souches. Tou·tes les patient·es ont reçu une anesthésie générale avant la réalisation du bloc. Une anesthésie neuraxiale à injection unique a été réalisée chez 241 patient·es (54,8 %), un bloc du plexus brachial chez 27 patient·es (6,1 %) et des blocs du nerf fémoral/sciatique chez 17 (3,9 %) patient·es. Des blocs nerveux neuraxiaux, du plexus brachial et fémoraux/sciatiques continus ont été réalisés chez 149 (33,9 %), quatre (0,9 %) et sept (1,6 %) personnes, respectivement. Des chirurgies majeures et complexes ont été réalisées chez 161 (36,6 %) et 72 (16,4 %) patient·es, respectivement, et des cathéters continus ont été insérés chez 50,3 % des personnes bénéficiant d'une intervention chirurgicale majeure et chez 91,7 % des personnes bénéficiant d'une chirurgie majeure complexe. Une douleur intense a été signalée par le personnel soignant chez 68 patient·es (15,5 %) ayant reçu des interventions analgésiques non opioïdes. CONCLUSION: Malgré l'utilisation de l'anesthésie régionale, environ 15 % des patient·es atteint·es de PC spastique bénéficiant d'une chirurgie orthopédique pour leur paralysie cérébrale spastique ont ressenti une douleur intense qui a répondu aux ajustements du traitement. ENREGISTREMENT DE L'éTUDE: CTRI.nic.in (027002); enregistrée le 5 août 2020.

Crouch Gait in Cerebral Palsy: Current Concepts Review.

Background and Objective: Crouch gait is the most common pathological gait pattern in cerebral palsy and is commonly seen in patients with spastic diplegia. It is characterized by excessive knee flexion throughout the stance phase of gait cycle. The aim of this review is to discuss the current literature about CG for a more comprehensive understanding. Methods: A literature review about various aspects of crouch gait in cerebral palsy was undertaken. This included its etiology and pathophysiology, biomechanics in crouch gait, natural history of untreated crouch gait, clinical and radiological evaluation and different modalities of available treatment. Results: The etiology is multifactorial and the pathophysiology is poorly understood. This makes its management challenging, thereby leading to a variety of available treatment modalities. Inadvertent lengthening of muscle-tendon units is an important cause and can be avoided. A meticulous clinical and radiological evaluation of patients, supplemented by observational and instrumented gait analysis is mandatory in choosing correct treatment modality and improving the treatment outcome. Younger children can be managed satisfactorily by various non-operative methods and spasticity reduction measures. However, crouch gait in cerebral palsy has a progressive natural history and surgical interventions are needed frequently. The current literature supports combination of various soft tissue and bony procedures as a part of single event multilevel surgery. Growth modulation in the form of anterior distal femur hemiepiphysiodesis for correction of fixed flexion deformity of knee has shown encouraging results and can be an alternative in younger children with sufficient growth remaining. Conclusions: In spite of extensive research in this field, the current understanding about crouch gait has many knowledge gaps. Further studies about the etiopathogenesis and biomechanics of crouch using instrumented gait analysis are suggested. Similarly, future research should focus on the long term outcomes of different treatment modalities through comparative trials.

Infraclavicular block in children: Is blocking lateral or posterior cord equally successful?

Background and Aims: The most effective approach for infraclavicular brachial plexus block in adults is to target the posterior cord, usually situated posterior to axillary artery. However, we do not know if this can be extrapolated in children. Our primary objective was to compare the clinical success rate of ultrasound guided infraclavicular brachial plexus block in children with local anesthetic injection aimed at two targets. These were posterior to axillary artery (posterior cord) and lateral to axillary artery (lateral cord). The secondary objectives involved need for intraoperative rescue analgesia, evaluation of duration of analgesia, incidence of complications such as pneumothorax and arterial puncture, comparison of postoperative pain scores and fluoroscopic dye spread pattern was also observed. Material and Methods: It was a randomized, prospective pilot study. Forty children undergoing forearm and hand surgeries were randomized to two groups, in accordance with the target site of the block. Target sites of Group P (20 patients) and Group L (20 patients) were posterior and lateral to the axillary artery, i.e., posterior and lateral cord respectively. Aforesaid objectives were assessed. SPSS (Version 15.0) statistical package was used. Comparison between Group L and P was by using student's unpaired t test for age and weight. Fisher's exact probability test was applied to compare percentages between groups. Results: Blocks of both groups were equally successful. No patient required intraoperative rescue analgesia. Duration of analgesia was comparable. Both groups had no major complications and similar postoperative pain scores. Conclusions: The success rate of infraclavicular brachial plexus block by aiming at the lateral and posterior cord was similar.

Adverse effects following botulinum toxin A injections in children with cerebral palsy.

The study aimed to analyze the adverse events associated with botulinum toxin A (BoNT-A) injections in children with cerebral palsy (CP). The literature search was completed using the Medline, PubMed, Google Scholar, Scopus, and Cochrane Library databases from the earliest date possible up to December 2021. Search terms included 'botulinum toxin', 'cerebral palsy', 'spasticity', 'adverse effects', 'side effects', 'undesirable effects', 'complications', 'lower limb', 'upper limb', and 'children' including combinations of index and free-text terms. Fifty-five studies were included in the study. Data on 6333 pediatric patients and more than 14 080 BoNT-A injections were collected. Respiratory symptoms and respiratory tract infections were the most frequently registered adverse events (AEs). Other common AEs included procedural/focal AEs, flu-like symptoms, and asthenia. Sentinel events including four cases of death were reported. AEs were more frequent and severe in high-dose patients; however, the capacity of BoNT-A to spread systemically remains unclear. Since severe adverse events are not common, further research is needed to collect more definitive clinical and homogeneous data to support the findings of the present research and clarify the safety profile of BoNT-A, especially regarding the incidence of respiratory issues and complications in GMFCS IV or V patients.

The Proteasome and Ageing.

The proteasome is a multi-subunit proteolytic complex that functions to degrade normal proteins for physiological regulation and to eliminate abnormal proteins for cellular protection. Generally, the proteasome targets substrate proteins that are marked by attachment of multiple ubiquitin molecules. In various types of cells in an organism, damage to proteins occurs both from internal sources such as reactive oxygen species and from external ones such as UV radiation from the sun. The proteasome functions to protect the cells by degrading damaged proteins. With ageing, however, the capacity of the proteasome to degrade damaged proteins is reduced as indicated by evidence gathered by many studies. Studies on ageing in muscle, skin, and brain show that with age catalytic activity of the proteasome is decreased and the expression of proteasome subunits is altered. Age-related accumulation of damaged or misfolded proteins causes further reduction of proteasome activity. Abnormal proteins also accumulate as a result of age-related neurodegenerative diseases. Deficits in proteasome activity might be responsible for accumulation of protein aggregates and thus contribute to the pathology. Results from several studies suggest a link between the proteasome and longevity. This chapter reviews the various ways in which the proteasome is associated with the ageing process and examines evidence gathered from investigations on cultured cells, model organisms, and humans.

Effect of physical properties of synthesized protic ionic liquid on carbon dioxide absorption rate.

The concentration of carbon dioxide gas has accelerated over the last two decades which cause drastic changes in the climatic conditions. In industries, carbon capture plants use a volatile organic solvent which causes many environmental threats. So, a low-cost green absorbent has been formulated with nontoxicity and high selectivity properties for absorbing carbon dioxide gas. This paper contains the synthesis process along with the structure confirmation using 1H NMR, 13C NMR, FT-IR, and mass spectroscopy. Density, viscosity, and diffusivity are measured at different ranges with standard instruments. The kinetic studies were also conducted in a standard predefined-interface stirred cell reactor. The kinetic parameters were calculated at different parameters like agitation speeds, absorption temperature, initial concentrations of ionic liquid, and partial pressure of carbon dioxide. The reaction regime of carbon dioxide absorption is found to be in fast reaction kinetics with pseudo-first-order. The reaction rate and the activation energy of CO2 absorption are experimentally determined in the range of 299 to 333 K with different initial concentrations of ionic liquid (0.1-1.1 kmol/m3). The second-order rate constant and activation energy of carbon dioxide absorption in the synthesized ionic liquid is found to be 9.48 × 103 m3 mol-1 s-1 and 16.61 kJ mol-1 respectively. On increasing the viscosity of the reacting solvent, the diffusivity of CO2 gas molecules decreases, and thus the rate of absorption decreases. This solvent has shown great potential to absorb CO2 at a large scale.

Mitigating exhaust emissions in CI engines using butanol-diesel-water microemulsions.

The current research work examines the usability of surfactant-free microemulsion fuels as a substitute in CI engines, with alcohol being used as an amphi-solvent. Studies were carried out on different compositions of microemulsions with 35% volume and 40% volume butanol, named ME35 and ME40, having 57.8-64.4% volume diesel and 0.6-2.2% volume water. Most of the microemulsions had properties such as viscosity, specific gravity, cloud point, and sulfur content comparable to those of diesel. The heating values and cetane indices of the microemulsions were 0.09-8.7% and 19.4-28.7% lower than diesel due to the addition of water and alcohol. The water and sediments percentages were found to be low, even after the addition of water, indicating the microemulsions were stable. ME40 showed an average of 0.6-3.5% improvement in BTE, but the BSFC was also increased by 5.3-8.9%. The emissions of HC, NOx, and PM showed an average decrease of 19.0-48.9%, 14.8-41.9%, and 10.06-50.24%, respectively, for all the microemulsions at all the loads. The CO emissions were lower at higher loads and vice versa, but the average CO emissions showed 5.16-31.9% decrease due to significant reductions at higher loads. It could, therefore, be concluded that microemulsions are a promising sustainable and cleaner substitute for diesel. Synopsis Microemulsion fuels successfully replaced up to 42% of diesel, with significant reduction in emissions of CO, HC, NOx, and PM.

Post Surgical Non-tuberculous Mycobacterium: A Case Series.

Background There has been an increase in non-tuberculous mycobacteria (NTM) infection reports in humans. Surgeons are concerned about the link between them and surgical site infections. As a result, it has been challenging to determine just how common this illness is. A two-year study by the authors examines the occurrence of NTM infections after different surgical procedures. Design and methods Researchers at a tertiary care hospital in central India performed this prospective study over two years. NTM was found in six of the 25 instances of post-surgical wound infections. Ziehl-Neelsen staining, Auramine O-Rhodamine fluorescence staining, Multiplex Real-Time PCR, and Genotyping were used to identify the species. Results M. fortuitum, M. chelonae and M.kansasii were isolated from discharge in 2 cases each respectively. NTM isolates evaluated for antibiotic susceptibility pattern were all sensitive to Clarithromycin (100%). One case with prolonged healing had to be intervened with amikacin along with clarithromycin. Conclusion NTM is an infection of uncommon nature which can occur following surgical procedures. Identification of these organisms through sensitive techniques and appropriate therapeutic regimen formulation must be done to tackle this growing menace in health care setups.

Hip Displacement in Cerebral Palsy: The Role of Surveillance.

INTRODUCTION: Hip displacement is common in cerebral palsy (CP) and is related to the severity of neurological and functional impairment. It is a silent, but progressive disease, and can result in significant morbidity and decreased quality of life, if left untreated. The pathophysiology of hip displacement in CP is a combination of hip flexor-adductor muscle spasticity, abductor muscle weakness, and delayed weight-bearing, resulting in proximal femoral deformities and progressive acetabular dysplasia. Due to a lack of symptoms in the early stages of hip displacement, the diagnosis is easily missed. Awareness of this condition and regular surveillance by clinical examination and serial radiographs of the hips are the key to early diagnosis and treatment. HIP SURVEILLANCE PROGRAMMES: Several population-based studies from around the world have demonstrated that universal hip surveillance in children with CP allows early detection of hip displacement and appropriate early intervention, with a resultant decrease in painful dislocations. Global hip surveillance models are based upon the patients' age, functional level determined by the Gross Motor Function Classification system (GMFCS), gait classification, standardized clinical exam, and radiographic indices such as the migration percentage (MP), as critical indicators of progressive hip displacement. CONCLUSION: Despite 25 years of evidence showing the efficacy of established hip surveillance programmes, there is poor awareness among healthcare professionals in India about the importance of regular hip surveillance in children with CP. There is a need for professional organizations to develop evidence-based guidelines for hip surveillance which are relevant to the Indian context.