MyoVision-US: an Artificial Intelligence-Powered Software for Automated Analysis of Skeletal Muscle Ultrasonography.

Introduction/Aims: Muscle ultrasound has high utility in clinical practice and research; however, the main challenges are the training and time required for manual analysis to achieve objective quantification of morphometry. This study aimed to develop and validate a software tool powered by artificial intelligence (AI) by measuring its consistency and predictability of expert manual analysis quantifying lower limb muscle ultrasound images across healthy, acute, and chronic illness subjects. Methods: Quadriceps complex (QC [rectus femoris and vastus intermedius]) and tibialis anterior (TA) muscle ultrasound images of healthy, intensive care unit, and/or lung cancer subjects were captured with portable devices. Automated analyses of muscle morphometry were performed using a custom-built deep-learning model (MyoVision-US), while manual analyses were performed by experts. Consistency between manual and automated analyses was determined using intraclass correlation coefficients (ICC), while predictability of MyoVision -US was calculated using adjusted linear regression (adj.R 2 ). Results: Manual analysis took approximately 24 hours to analyze all 180 images, while MyoVision - US took 247 seconds, saving roughly 99.8%. Consistency between the manual and automated analyses by ICC was good to excellent for all QC (ICC:0.85-0.99) and TA (ICC:0.93-0.99) measurements, even for critically ill (ICC:0.91-0.98) and lung cancer (ICC:0.85-0.99) images. The predictability of MyoVision-US was moderate to strong for QC (adj.R 2 :0.56-0.94) and TA parameters (adj.R 2 :0.81-0.97). Discussion: The application of AI automating lower limb muscle ultrasound analyses showed excellent consistency and strong predictability compared with human analysis. Future work needs to explore AI-powered models for the evaluation of other skeletal muscle groups.

A quantitative evaluation of the effect of meals on macular thickness in diabetic patients with diabetic macular edema.

PURPOSE: Central subfoveal thickness measurement is used in a large number of clinical trials to monitor the progression and treatment response of diabetic macular edema (DME) in patients of diabetic retinopathy (DR). Several studies have been carried out to investigate various factors affecting the central subfoveal thickness in order to minimize errors in the testing. We planned a study to investigate the effect of meals on central macular thickness (CMT) in patients with DME and compare that with nondiabetic patients. METHODS: In this observational study, 50 patients of diabetes with DME and 50 normal controls were included. Macular thickness was measured after overnight fasting and 2 h postprandial for both the groups. Any changes in morphology and CMT were evaluated. RESULTS: Each group had 22 females and 28 males with a mean age of 60.6 ± 6.6 in the diabetic group and of 49.66 ± 11.13 in the control group. Reduction in the CMT was noticed after the meals (mean: -9.78 ± 12.77 µm; P < 0.001) in those with DME as compared to the control group. This was more prominent in those who had intraretinal cystic spaces (17.14 ± 10.33 µm) and neurosensory detachment (66 µ). Patients with high blood sugar levels had higher CMT and a greater reduction in thickness was noticed in them postprandially (r = 0.414; P = 0.0028). CONCLUSION: The CMT values in patients with DME are significantly affected by meals. Hence, an attempt should be made to measure CMT during the fasting state for more accurate results.

Construct and criterion validity of muscle ultrasonography for assessment of skeletal muscle in patients recovering from COVID-19.

Background: The purpose was to investigate the content, construct, and criterion validity of muscle ultrasound in a mixed cohort of participants recovering from mild and critical COVID-19. Methods: A secondary analysis of a prospective cross-sectional study was conducted on data obtained from a battery of muscle and physical function assessments including a muscle biopsy and muscle ultrasonography (US). Rectus femoris (RF) muscle thickness (mT), quadricep complex (QC) mT, RF muscle cross-sectional area (CSA) using 2D freeform trace and estimated from Feret's diameter, and RF echo intensity (EI) were assessed with US. Muscle fiber CSA, fiber type, protein content in muscle fibers, extracellular matrix content (ECM; wheat-germ agglutin), and percent area of collagen in ECM (picrosirius red) were examined from vastus lateralis muscle biopsies. Spearman rho correlations (r) were performed to assess validity of ultrasound parameters. Results: Thirty-three individuals participated including 11 patients surviving critical COVID-19, 15 individuals recovering from mild-COVID, and 7 controls. There were several significant correlations between RF mT, QC mT, RF CSA, and RF EI with age, comorbid burden, body-mass index, and measures of muscle strength, muscle power, and physical function (range r = 0.35-0.83). RF Feret's CSA correlated to CSA of type II muscle fibers (r = 0.41, p = 0.022) and the average size of all muscle fibers (r = 0.39, p = 0.031). RF EI was correlated with collagen in muscle ECM (r = 0.53, p = 0.003) and protein content in muscle tissue (r = -0.52, p = 0.012). Conclusion: Muscle size and quality measured using US has moderate content and construct validity, and to lesser extent, fair to moderate criterion validity in a mixed cohort of individuals recovering from COVID. Muscle ultrasound quality (EI) appears to be sensitive at detecting muscle dysfunction as it is associated with strength, power, physical function, and collagen distribution in a mixed group of individuals recovering from COVID-19.

Current Practice Review in the Management of Acute Respiratory Distress Syndrome.

Acute respiratory distress syndrome (ARDS) presents as an acute inflammatory lung injury characterized by refractory hypoxemia and non-cardiac pulmonary edema. An estimated 10% of patients in the intensive care unit and 25% of those who are mechanically ventilated are diagnosed with ARDS. Increased awareness is warranted as mortality rates remain high and delays in diagnosing ARDS are common. The COVID-19 pandemic highlights the importance of understanding ARDS management. Treatment of ARDS can be challenging due to the complexity of the disease state and conflicting existing evidence. Therefore, it is imperative that pharmacists understand both pharmacologic and non-pharmacologic treatment strategies to optimize patient care. This narrative review provides a critical evaluation of current literature describing management practices for ARDS. A review of treatment modalities and supportive care strategies will be presented.

Triplet of doubles: Double anterior chamber, double descemet membranes, and double rhexis.

A 52-year-old women underwent penetrating keratoplasty for total corneal opacity after healed microbial keratitis with an uneventful postoperative period until six months when she developed gross diminution of vision. During examination, she was detected to have a membrane in the anterior chamber, creating a double anterior chamber with a total cataract. The graft was clear, and sutures were intact. Anterior segment optical coherence tomography (OCT) showed the membrane in the anterior chamber crossing the graft host junction, suggesting this membrane to be retained host descemet membrane. This was confirmed on histopathological examination. Double rhexis (descemetorhexis and capsulorhexis) was performed with cataract removal and intraocular lens (IOL) implantation, and patient had good visual recovery postoperatively.

Upper Cervical Leiomyoma in an Adolescent Male.

Introduction: Leiomyomas are benign epithelial tumors with a female preponderance usually in the uterus, gastro-intestinal tract and skin. They are well-capsulated tumors with no mitotic activity and little pleomorphism. Primary leiomyoma in the upper cervical spine region is rare and the occurrence of these lesions in young immunocompetent males is extremely rare. Case Report: A 15-year-old male had swelling over the nape of the neck for 4 years with slight difficulty in neck movements for a few months. Asymptomatic 4 years back be developed a painless swelling at the nape of the neck on the right side initially the size of a pea which gradually increased size. A 10x8cm firm, on-tender and non-pulsatile swelling at the nape of the neck on the right extending from the occipital nuchal line and crossing the midline up to the posterior border of the sternomastoid. The skin over the swelling wasn't adherent and the swelling did not reduce on neck movements. Neck movements were terminally restricted with restriction on rotation towards the right. Routine X-ray's and magnetic resonance imaging were suggestive of a soft tissue mass in the inter-muscular plane on the posterior aspect more on the right side with a cystic component and causing thinning of the C2 lamina with no intraspinal extension. Biopsy was done. Findings were suggestive of a spindle cell benign tumor. Posterior en bloc excision was planned and the lesion blog with the entire capsule was excised and sent for histopathology which revealed the lesion was a leiomyoma. The patient has shown no clinical or radiological evidence of recurrence at 4 year fol-low-up. Conclusion: Leiomyomas in the upper cervical spine is extremely rare in adolescent immunocom-petent male.

Multiple Cantilever K-wiring Technique for Severely Comminuted Articular Fragments in Neglected Distal Humerus Fracture with Anterior Elbow Dislocation: A Case Report.

Introduction: Anterior dislocation of the elbow is comparatively less frequent and is often associated with fractures of the distal humerus. Such injuries require surgical intervention at the earliest but with the surge of COVID-19 pandemic and different protocols being followed by surgeons, such cases are getting neglected. We present a 5-week-old neglected anterior dislocation of the right elbow joint with lateral condyle and medial epicondyle humerus fracture and a unique cantilever K-wiring technique used for its treatment. Case Presentation: A 30-year-old man presented with pain, deformity, and limited range of movement of his right elbow joint and a non-healing wound over the olecranon after he had a road traffic accident 5 weeks back. The patient had been initially treated in a local hospital where he tested positive for COVID-19 and was managed conservatively. Radiographs revealed lateral condyle and medial epicondyle humerus fracture and an unreduced anterior dislocation of the right elbow joint. Conclusion: Neglected fracture-dislocation of the elbow is challenging and is further complicated by comminuted fragments with loss of bone stock. A unique use of multiple Kirschner wires in a cantilever fashion provides a good fixation alternative for such cases.

To Study the Role of Serum Homocysteine Levels and Ocular Involvement in Retinal Vasculitis.

Idiopathic retinal vasculitis is a chronic disease of unknown aetiology which results in ocular morbidity in patients of productive age group. Homocysteine has been implicated in various ocular conditions like age-related macular degeneration, retinal vein occlusions, diabetic retinopathy, and optic nerve diseases. We conducted a study to investigate the relation between serum homocysteine levels and retinal vasculitis at a tertiary care centre in North India. In this case-control study, 32 cases and 64 controls were included and the duration was from June 2017 to March 2019. Serum homocysteine of cases and controls was detected by reflectance photometry using VITROS Chemistry Products HCY 2 (Homocysteine) and the normal range of serum homocysteine as per this method was 6.60 to 14.80 micro mol per litre. Our study found that of the total 32 retinal vasculitis patients, serum homocysteine was raised in 65.62% (21 cases out of 32) and in 70.31% of control group (45 out of 64). Chi square test results showed that there was no significant association found between S. homocysteine levels and Reticular vasculitis (P: 0.64). The two groups were comparable in terms of the age with mean ± SD in cases being 33.47 ± 8.336 years and controls being 35.16 ± 8.568 years with a P value of 0.37 being statistically insignificant. The data collected was analysed using SSPS-16 (Statistical Package for Social Sciences Version 16) software and test of association was Odd's ratio. Power of study was 80% and P < 0.05 is considered statistically significant. We found that there is no significant association between raised serum homocysteine and retinal vasculitis (with P < 0.64). Odds ratio was 0.80(0.33-1.99) implying that the cases and controls were statistically significantly different with respect to homocysteine levels.

Osteochondroma Presenting Clinically with Carpal Tunnel Syndrome in a 12-Year-old Boy.

INTRODUCTION: An exostosis is a benign growth of bone, which when capped with cartilage is called osteochondroma, which can appear as solitary or multiple, mostly affecting the long bones, pelvis, and shoulder region. The prevalence of known solitary exostosis is 1-2% in the general population. They are slow growing lesions with rare malignant transformation. In patients with a solitary exostosis, the chance of developing a chondrosarcoma out of an exostosis is around 1%. CASE REPORT: A 12-year-old boy presented to our outpatient department with complaints of pain, and swelling at the right wrist since 1 year and tingling numbness on and around palmar aspect of index and middle finger since 6 months. The swelling was of size 3 cm × 2 cm, Tinel's sign was positive. His blood parameters were normal. X-ray showed exostoses. Magnetic resonance imaging was suggestive of osteochondroma. Nerve conduction study was normal. Excision biopsy confirmed the diagnosis and also relieved all symptoms. CONCLUSION: Our case report is unique in its own way as it reminds us that when presented with a case of osteochondroma of the distal radius in children, carpal tunnel syndrome can also occur.

Innovative technique of mini-simple limbal epithelial transplantation in pediatric patients.

In this article, we introduce a modified technique of minor ipsilateral simple limbal epithelial transplantation (mini-SLET) in pediatric patients of limbal stem cell deficiency (LSCD). Two children with unilateral partial LSCD underwent the innovative technique of mini-SLET, where harvested limbal tissues were placed over the raw cornea and were covered with amniotic membrane. Both patients were followed till 9 months. Both cases showed favorable outcome and uneventful recovery. Results were comparable with the classical technique. This innovative modification of mini-SLET is safe, feasible, and an effective alternative with favorable visual outcome especially in pediatric population. It can be a breakthrough for LSCD management in developing countries with limited resources.

Anthropometric analysis of linear parameters of the Indian nose: A cross-sectional study and comparison with literature.

BACKGROUND: Many studies have been done to find out the accepted "ideal" appearance and proportions of the nose. However, much of this work has been limited to the facial architecture of the North American Caucasian population. Therefore, most beauty standards are driven by Western influences. AIMS AND OBJECTIVES: To measure different standard linear parameters of Indian faces and compare them with the studies found in the literature, in an endeavor to help in preoperative planning in rhinoplasty while maintaining their ethnicity. METHODS: This was a hospital-based cross-sectional study of 500 subjects. A total of 21 standard measurements were noted directly from the faces, and 11 proportional values calculated. Mean values with standard deviations were statistically used for comparisons with studies in the literature. RESULTS: There were significant differences between male and female subjects of our study in 16 variables. The proportional indices calculated also revealed significant differences statistically in 6 out of 11 measurements between male and female subjects. Significant differences were found in most of the parameters when our data were compared with Indian American, North American white population, Korean, Chinese, and African American. CONCLUSIONS: Facial measurements in the Indian population are different from those of other races, such as nasal index: (al-al × 100/n-sn), sn-prn x 100/ al-al index, and sn-prn x 100/n-Sn index, and it is important to have own set of parameters to act as standards guiding esthetic nasal surgeries while maintaining ethnicities. Our study is an attempt at the same. However, because of the huge diversity of the Indian population, it requires larger studies from different regions to achieve the final aim to create standards for cosmetic rhinoplasties.

Study of correlation between stereopsis and retinal nerve fiber layer thickness in cases of glaucoma.

BACKGROUND: Glaucoma is an important and common optic neuropathy characterized by progressive loss of retinal ganglion cells and associated morphological changes to the optic nerve and retinal nerve fiber layer (RNFL). The most common assessment of visual function in glaucoma uses perimetric measurements of visual sensitivity. Only few studies have evaluated the binocular function in patients with glaucoma. This study was taken up to establish the correlation of RNFL thickness, in glaucoma, with near and distance stereopsis. METHODS: This pilot, cross-sectional observational study included 100 diagnosed cases of glaucoma and 100 normal participants as controls, studied over a period of one year. The records of all the participants were checked, and only established cases of glaucoma after fulfilling the inclusion and exclusion criteria were included. Analysis of the RNFL using spectral-domain optical coherence tomography was carried out. All the participants were thereafter evaluated for stereoacuity by near (at 40 inches) and distance (at 3 meter) Randot stereoacuity charts. RESULTS: There was a negative correlation between the RNFL thickness and the absolute value of streoacuity (-0.303 for distance versus -0.101 for near in cases and -0.308 for distance and -0.416 for near in control group), decreasing the actual functional stereoacuity, therefore the cases with lower RNFL thickness had lower stereoacuity both for distance and near, however it was statistically significant only for distance (p=0.002). CONCLUSION: Functional aspects, such as stereoacuity, may also be affected in the glaucoma because of decrease in RNFL thickness. Therefore, binocular status should also be evaluated in cases of glaucoma.

Management of Post-DALK Recipient Posterior Stromal Scarring: A Novel Approach.

AIM: Management of recipient posterior stromal scarring following deep anterior lamellar keratoplasty (DALK) by a novel approach. METHODS: A side port knife bent at the tip is used to make a linear incision in the host posterior stroma. Plane between host posterior stroma and DALK tissue is separated using a reverse sinskey hook and multiple radial incisions are made using microvitroretinal scissors. The recipient posterior stromal wedges are removed using 20G vitrector with a cut rate of 800 cuts/min. A Descemet stripping endothelial keratoplasty lenticule is inserted into the anterior chamber and apposed to the posterior surface of DALK tissue using air tamponade. RESULT: This technique was used in 10 patients who showed clearing of the scarring after the surgery with good apposition of the donor graft to the previous DALK tissue. Conclusion: This is a sutureless, relatively simple, inexpensive, and effective novel surgical technique that avoids complications of open sky procedure and can be replicated in any ophthalmologic operation theatre setup.

Aggressive Vertebral Hemangioma Causing Recurring Myelopathy -A Rare Case Report and Review of Literature.

Introduction: Vertebral hemangiomas although benign vascular lesions few of these may be ag-gressive causing osseous, extra-osseous and/or epidural expansions with recurrence rate as low as 3%. It should be considered as one of the important differentials while dealing with lytic lesions in the dorsal spine causing compressive myelopathy. Case Report: A 16-year-old female came with an acute history of paraparesis with bladder in-volvement. She was diagnosed of vertebral hemangioma of D9 for which she underwent surgical decompression and fixation. At present, she had paraparesis with a sensory level of D10 on exami-nation. After radiological investigations (X-ray and MRI) she had high intensity signals in the extra osseous portion of D9 with significant neural compression indicating recurrence of vertebral he-mangioma. She underwent decompression with long segment instrumentation with prior arterial embolization. Histopathology features were suggestive of hemangioma and our diagnosis of recur-rence was confirmed. At 2 weeks, the patient had improved neurology with partial sensory recovery and Grade 2 power in the right lower limb and Grade 1 power in the left lower limb. Histopathology report confirmed the diagnosis of hemangioma indicating recurrence. At 6 months follow-up after aggressive rehabilitation, the patient was spastic and improved to Grade 3 power in the left lower limb and Grade 4 power in the right lower limb. The sphincteric control was also found to be fair at 1 year follow-up. Discussion: Vertebral hemangiomas when causing progressive neurological deficit warrant surgical decompression. The choice of intervention depends on location and extent of the tumor. Due to their high vascularity, it is advisable for to preoperatively carry out arterial embolization. Conclusion: Although commonly asymptomatic, vertebral hemangiomas may present as compressive myelopathy. Therefore, they should be detected early, intervened and followed up regularly to detect recurrence to prevent worsening of neurology and function.

Endogenous endophthalmitis secondary to Burkholderia cepacia: A rare presentation.

Burkholderia cepacia (previously known as Pseudomonas cepacia) is low virulent, gram negative bacilli, known to cause infections in immunocompromised hosts. There are reports about this organism causing keratitis, acute or delayed postoperative, or post traumatic endophthalmitis. Persistence of infection and poor visual outcome are well known complications of infection caused by this organism. Endogenous endophthalmitis due to Burkholderia cepacia is rare. There is no such case report available of endogenous endophthalmitis caused by these bacteria in the literature, where it is presented as retinal abscess and retinal vasculitis. Our aim is to report such a rare case from our hospital, which was treated with systemic and intravitreal antibiotics, with control of infection.

Interrater Reliability of Muscle Ultrasonography Image Acquisition by Physical Therapists in Patients Who Have or Who Survived Critical Illness.

OBJECTIVE: Previous studies have demonstrated that muscle ultrasound (US) can be reliably performed at the patient bedside by novice assessors with minimal training. The primary objective of this study was to determine the interrater reliability of muscle US image acquisition by physical therapists and physical therapist students. Secondarily, this study was designed to elucidate the process for training physical therapists to perform peripheral skeletal muscle US. METHODS: This was a cross-sectional observational study. Four novices and 1 expert participated in the study. Novice sonographers engaged in a structured training program prior to implementation. US images were obtained on the biceps brachii, quadriceps femoris, and tibialis anterior muscles in 3 groups: patients in the intensive care unit, patients on the hospital ward, and participants in the outpatient gym who were healthy. Reliability of image acquisition was analyzed compared with the expert sonographer. RESULTS: Intraclass correlation coefficient values ranged from 0.76 to 0.97 with an average for all raters and all muscles of 0.903, indicating excellent reliability of image acquisition. In general, the experienced physical therapist had higher or similar intraclass correlation coefficient values compared with the physical therapist students in relation to the expert sonographer. CONCLUSIONS: Excellent interrater reliability for US was observed regardless of the level of experience, severity of patient illness, or patient setting. These findings indicate that the use of muscle US by physical therapists can accurately capture reliable images in patients with a range of illness severity and different clinical practice settings across the continuum of care. IMPACT: Physical therapists can utilize US to obtain images to assess muscle morphology. LAY SUMMARY: Physical therapists can use noninvasive US as an imaging tool to assess the size and quality of peripheral skeletal muscle. This study demonstrates that physical therapists can receive training to reliably obtain muscle images in patients admitted to the intensive care unit who may be at risk for muscle wasting and may benefit from early rehabilitation.

The fear and risk of community falls in patients following an intensive care admission: An exploratory cohort study.

BACKGROUND: Muscle weakness and impairments in physical functioning are well-recognised sequelae after critical illness. Whether individuals have a higher risk of community falls and a fear of falling has not been examined amongst individuals after critical illness. OBJECTIVES: The objective of this study was to explore the prevalence of falls, fear of falling, and fall risk in intensive care unit (ICU) survivors over a 6-month period after hospital discharge. METHODS: This was a nested exploratory study within a medical ICU. Fall prevalence was measured in line with established guidelines over 6 months after ICU discharge. Fear of falling and prediction of fall risk were assessed at 2, 4, and 6 months after discharge. RESULTS: Twelve individuals were included. Half of the cohort (n = 6) had at least one fall, with one-third sustaining more than one fall. There were 17 falls reported across the six individuals. Injuries requiring medical intervention were reported with five falls. Almost one-third were classified as 'moderate' to 'severe' injurious falls. Loss of balance and fatigue were reported as the main contributors to the falls. All individuals who had a fall reported a severe fear of falling at 2 months. Individuals classified as having 'moderate' to 'high' risk of falls at 2 months were more likely to have at least one fall. CONCLUSIONS: This study suggests that ICU survivors may have a high fall risk, fear of falling, and fall prevalence, which can result in significant injury.

New use of a pupillary expansion ring to avoid intraoperative positive vitreous pressure during triple procedures.

Positive vitreous pressure can complicate cataract surgery during a triple procedure by inadvertently extending the capsulorhexis. This occurs because the procedure is open sky and positive vitreous pressure cannot be countered by injecting ophthalmic viscosurgical devices. We describe a new use of a pupillary expansion ring (Malyugin) to achieve a stable open anterior chamber under open sky during triple procedures. The scrolls are tucked under cut margins of the host cornea to create the capsulorhexis, the cataractous nucleus is removed, and an intraocular lens (IOL) is implanted in the bag. This technique is especially useful in cases of hypermature cataract and nondilating pupils with positive vitreous pressure in patients having triple procedures. The technique provides a stable open anterior chamber, increasing to the safety of the procedure and the chance of achieving a continuous curvilinear capsulorhexis and IOL implantation in the capsular bag.