Early versus delayed thromboprophylaxis with LMWH in pelvic-acetabular trauma- a prospective study

BACKGROUND

Delayed presentation of pelvic-acetabular fractures is a common scenario in developing countries and there is usually a delay of more than 24 h in their presentation.

OBJECTIVES

We aim to comparatively analyse early(<24 h) versus delayed (>24 h) thromboprophylaxis with low molecular weight heparin (LMWH) in prevention of deep venous thrombosis (DVT) in Pelvic Acetabular fractures.

METHODS

Patients of pelvic-acetabular fractures who presented during 1 year of study period were divided into 2 groups after exclusion of patients with contraindications for thromboprophylaxis. Group A included patients who received LMWH prophylaxis within 24 h of injury. Group B included patients who received LMWH prophylaxis after 24 h of injury. All patients underwent CT venography at day 14 and were followed up with doppler ultrasound on 4th and 8th week.

RESULTS

110 patients with pelvic-acetabular fractures were included after exclusion of 61 patients. 4 out of 29 patients in group A (13.8%) and 12 out of 81 patients (14.8%) in group B developed DVT. There was no significant difference in incidence of DVT between Group A and B (P value-0.893).

CONCLUSION

There was no difference between early and delayed thromboprophylaxis with LMWH in pelvic-acetabular trauma.

Fragmentation dynamics of CH3Clq+ (q = 2,3): theory and experiment

We use advanced theoretical treatments and energetic ion collision induced fragmentation to investigate the unimolecular decomposition dynamics of CH3Clq+ (q = 2,3) ions, where both obvious bond breaking and bond rearrangement products are observed.

Role of shear wave elastography of synovium to differentiate rheumatoid and tubercular arthritis

Background:

Synovitis is the underlying pathology in various arthritis, and sometimes, it is difficult to differentiate various arthritis clinically or even by imaging. The purpose of our study was to use shear wave elastography (SWE) to evaluate rheumatoid arthritis (RA) and tubercular (TB) arthritis and to differentiate them using synovial stiffness.

Methods:

The prospective study was performed on Supersonic Imagine Aixplorer Ultrasound (USG) machine using a linear array probe SL10-2 (2–10 MHz). A total of 29 participants, 15 of RA (ACR/EULAR criteria) and 14 of proven TB arthritis were included. Region of interest of 1 mm was applied on the hypertrophied synovium and quantitative SWE data in form of elasticity (kPa) and velocity (m/s) were measured. Discrete categorical data were presented as n (%). Mean values were recorded along with standard deviation and the range of values. To find a maximal cutoff value of elasticity and velocity - receiver operating characteristic curve were plotted.

Results:

The mean elasticity and velocity values were 54.81 ± 10.6 kPa and 4.2 m/s ± 0.42 for RA and 37 ± 10 kPa and 3.4 ± 0.47 m/s for TB group. Significant difference (P < 0.001) was seen in elastic modulus values between rheumatoid and TB group with cutoff of 43.6 kPa to differentiate the two groups (sensitivity – 86.7% and specificity – 80%). Similar significant (P < 0.001) results were seen with velocity values, with cutoff of 3.76 m/s (sensitivity – 86.7% and specificity – 80%).

Conclusion:

SWE shows the potential to be a useful adjunct to gray scale and color Doppler USG in differentiating various arthritis on the basis of elastic properties of the synovium. Elastic modulus and velocity are useful SWE quantitative parameters for synovial evaluation and can differentiate RA and TB arthritis.

Baseline renal dysfunction determines mortality following parathyroidectomy in primary hyperparathyroidism: analysis of Indian PHPT registry

INTRODUCTION

Primary hyperparathyroidism (PHPT) in India is mostly symptomatic with renal and skeletal complications. Evidence on mortality outcomes following parathyroidectomy from India, where the disease is predominantly symptomatic is limited.

MATERIAL AND METHODS

This was a prospective study to evaluate mortality outcomes in the Indian PHPT registry over the past 25 years (n = 464). Pre- and postoperative parameters and mortality data were obtained from medical records and/or by verbal autopsy, a method validated by WHO for data collection in settings where several deaths are noninstitutional. Patients were divided into survivor (SG) and nonsurvivor groups (NSG) to ascertain differences in presentation and the effect of parathyroidectomy.

RESULTS

The overall mortality was 8.8% at a median follow-up of 8 years (IQR 1-13) after parathyroidectomy. Chronic kidney disease was the most common background cause of death (43.5%), followed by pancreatitis (28.2%). NSG had significantly more frequent renal dysfunction (91.9% vs 73.9%), anaemia (50 vs 16.6%) and pancreatitis (24.3 vs 6.4%). PTH (61.9 vs 38.3 pmol/l) and baseline creatinine (97.2 vs 70.7 µmol/l) were significantly higher and eGFR lower (66.7 vs 90.7 ml/min/1.73m²) in the NSG than SG. By Cox proportional modelling, renal dysfunction [HR 2.88 (1.42-5.84)], anaemia [HR 2.45 (1.11-5.42)] and pancreatitis [HR 2.65 (1.24-5.66)] on univariate and renal dysfunction [HR 3.33 (1.13-9.77)] on multivariate analysis were significant for mortality. Survival curves demonstrated a significantly higher mortality with lower eGFR values.

CONCLUSIONS

Nonsurvivors in PHPT had greater prevalence and more severe baseline renal dysfunction than survivors. Survival after parathyroidectomy was significantly associated with estimated glomerular filtration rate at baseline.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle

Objectives

Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region.

Methods

We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval.

Results

A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement.

Conclusion

According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton’s neuroma, particularly using platelet-rich plasma and corticosteroids, respectively.

Key Points

• The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle.

• Strong consensus was obtained for all statements.

• The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton’s neuroma and PRP for plantar fasciitis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08125-z.

Identification of a Grotthuss proton hopping mechanism at protonated polyhedral oligomeric silsesquioxane (POSS) - water interface

The attachment and dissociation of a proton from a water molecule and the proton transfers at solid-liquid interfaces play vital roles in numerous biological, chemical processes and for the development of sustainable functional materials for energy harvesting and conversion applications. Using first-principles computational methodologies, we investigated the protonated forms of polyhedral oligomeric silsesquioxane (POSS-H⁺) interacting with water clusters (W_n, where n = 1-6) as a model to quantify the proton conducting and localization ability at solid-liquid interfaces. Successive addition of explicit water molecules to POSS-H⁺ shows that the assistance of at least three water molecules is required to dissociate the proton from POSS with the formation of an Eigen cation (H₉O₄⁺), whereas the presence of a fourth water molecule highly favors the formation of a Zundel ion (H₅O₂⁺). Reaction pathway and energy barrier analysis reveal that the formation of the Eigen cation requires significantly higher energy than the Zundel features. This confirms that the Zundel ion is destabilized and promptly converts in to Eigen ion at this interface. Moreover, we identified a Grotthuss-type mechanism for the proton transfer through a water chain close to the interface, where symmetrical and unsymmetrical arrangements of water molecules around H⁺ of protonated POSS-H⁺ are involved in the conduction of proton through water wires where successive Eigen-to-Zundel and Zundel-to-Eigen transformations are observed in quick succession.

Methods to address metal artifacts in post-processed CT images - A do-it-yourself guide for orthopedic surgeons

Computed tomography (CT) scans are often used for postoperative imaging in orthopedics. In the presence of metallic hardware, artifacts are generated, which can hamper visualization of the CT images, and also render the study ineffective for 3-D printing. Various solutions are available to minimize metal artifacts, and radiologists can employ these before or after processing the CT study. However, the orthopedic surgeon may be faced with situations where the metal artifacts were not addressed. To counter such problems, we present three do-it-yourself (DIY) techniques that can be used to manage metal artifacts.

Role of shear wave elastography in treatment follow-up of leprosy neuropathy

PURPOSE

Grayscale ultrasonography when complemented with shear wave elastography helps in better evaluation of treatment response of leprosy neuropathy and in guiding appropriate management of the patient. There is limited literature regarding the use of shear wave elastography in ulnar nerve neuropathy. Our purpose was to evaluate the role of shear wave elastography in assessing stiffness changes within the ulnar nerve during treatment of leprosy.

METHODS

This was a prospective study which included 30 patients diagnosed with leprosy neuropathy. Recruited patients were followed up, during the course of treatment, i.e. for 1 year. Serial ultrasonography of these patients was done at 0, 3, 6 and 12 months interval.

RESULTS

Significant (P < 0.05) decrease in elastography parameters was seen in transverse imaging plane between first and third, as well as first and fourth visits (mean stiffness and velocity pretreatment ~ 25.78 ± 18 kPa and 2.74 ± 0.98 m/s, mean stiffness and velocity post-treatment 15.67 ± 5.89 kPa and 2.24 ± 0.428 m/s). Although elastography parameters decreased during these visits in the long-axis imaging plane, they were not found to be statistically significant. However, gross morphology and cross-sectional area of the nerve did not change significantly across visits. Interestingly, elastography values were higher in patients with neuritis, though not statistically significant.

CONCLUSION

Shear wave elastography is a novel, upcoming modality in musculoskeletal imaging especially in the evaluation of peripheral neuropathy. It can act as an adjunct to grey-scale imaging, which can help in early diagnosis and in guiding treatment of leprosy neuropathy.

Primary elbow osteoarthritis presenting as ulnar nerve palsy with claw hand

A 59-year-old woman was referred with weakness, paraesthesia, numbness and clawing of the little and ring fingers for the last 2 years. MRI of the cervical spine was normal and nerve conduction velocity revealed abnormality of the ulnar nerve. Ultrasound and MRI showed medial osteophytes and effusion of the elbow joint with stretched and thinned ulnar nerve in the cubital tunnel. The patient underwent release and anterior transposition of the ulnar nerve with significant relief of symptoms.

Evaluation through outbreak simulation exercise points to the need for considerable improvement in the capacity of peripheral health workers for outbreak detection and response, South India, 2018

Background:

Outbreaks are emergencies, requiring skilled peripheral health workers in the health system. Given the lack of evaluation of the knowledge and practices of peripheral health workers regarding outbreak investigation and response, we surveyed to estimate the performance level of health workers in outbreak detection and response.

Methods:

We developed a simulation exercise based on hepatitis and fever outbreak to ascertain knowledge and skills in outbreak detection and response. Following a pilot test and with inputs from public health experts, we finalized the instrument in the local language. The simulation exercise was self-administered among all health inspectors (HI) (n = 39) from a district in South India responsible for outbreak investigation. We collected sociodemographic factors, training, education level, awareness about the surveillance program, outbreak triggers, and prior experience with an outbreak. We assigned a score of 0.25 for each correct response (range 0 to 10.75). We categorized a score of <75% as poor performance. The academic ethics committee of ICMR-National Institute of Epidemiology approved the protocol.

Results:

All the HIs were male except one. Median age is 51 years (Range: 37.5–54). The median years of service is 12 (range 5.3 to 23). Twenty-two received training, and fifteen had prior exposure to an outbreak in the previous year. The overall performance of HIs was poor, with the highest mark being below 40%. The median score in the section of history taking was 0.25 [interquartile range (IQR) 0–0.5], 31% (n = 12) scored zero. The median score in the section of data entry, analysis, and outbreak detection was 0.25 (0–0.25), 28% (n = 11) scored zero. The median score in the section of outbreak response was 0.75 (IQR 0.75–1.13), 5% (n = 2) scored zero.

Conclusion:

The HIs performed poorly in outbreak preparedness and response. We recommend improving their performance through field-epidemiology training and regular field or facility-based evaluations.

Eumycetoma of the Foot due to Fusarium solani in a Person with Diabetes Mellitus: Report of a Case and Review of Literature

Eumycetomas are chronic suppurative granulomas caused by fungi characterised by invasive tumefactive lesions, sinuses and discharging grains. Herein, we describe a case of pedal eumycetoma due to Fusarium solani sensu stricto in a person with diabetes mellitus. A 45-year-old gentleman presented with an insidious onset swelling over his right foot with nodules and discharging grains. He had received itraconazole and anti-tuberculous therapy elsewhere, without response. Re-evaluation included a biopsy which confirmed eumycetoma and newly diagnosed diabetes. Surgical excision followed by histopathological, microbiological and multigene sequencing analyses [translation elongation factor, calmodulin and internal transcribed spacer region of rDNA] of the mould on culture were performed. Histopathology revealed septate fungal hyphae amidst a dense inflammatory infiltrate (Splendore-Hoeppli) reaction. Oral voriconazole was started and good glycemic control attained. Tissue growth sequences showed > 99% similarity with Fusarium solani sensu stricto. Antifungal susceptibility testing showed lowest MIC to voriconazole (0.5 mg/L). The patient showed excellent response to combined therapeutic modality with a near-complete resolution in size of lesion and obliteration of sinuses following 4 months of therapy and is planned for prolonged voriconazole therapy till complete radiological resolution. Diabetes predisposes to fungal infections of foot but eumycetomas are uncommon. Combined surgery and antifungals can improve morbidity and avoid amputations.

Machine learning augmented near-infrared spectroscopy: In vivo follow-up of cartilage defects

OBJECTIVE

To assess the potential of near-infrared spectroscopy (NIRS) for in vivo arthroscopic monitoring of cartilage defects.

METHOD

Sharp and blunt cartilage grooves were induced in the radiocarpal and intercarpal joints of Shetland ponies and monitored at baseline (0 weeks) and at three follow-up timepoints (11, 23, and 39 weeks) by measuring near-infrared spectra in vivo at and around the grooves. The animals were sacrificed after 39 weeks and the joints were harvested. Spectra were reacquired ex vivo to ensure reliability of in vivo measurements and for reference analyses. Additionally, cartilage thickness and instantaneous modulus were determined via computed tomography and mechanical testing, respectively. The relationship between the ex vivo spectra and cartilage reference properties was determined using convolutional neural network.

RESULTS

In an independent test set, the trained networks yielded significant correlations for cartilage thickness (ρ = 0.473) and instantaneous modulus (ρ = 0.498). These networks were used to predict the reference properties at baseline and at follow-up time points. In the radiocarpal joint, cartilage thickness increased significantly with both groove types after baseline and remained swollen. Additionally, at 39 weeks, a significant difference was observed in cartilage thickness between controls and sharp grooves. For the instantaneous modulus, a significant decrease was observed with both groove types in the radiocarpal joint from baseline to 23 and 39 weeks.

CONCLUSION

NIRS combined with machine learning enabled determination of cartilage properties in vivo, thereby providing longitudinal evaluation of post-intervention injury development. Additionally, radiocarpal joints were found more vulnerable to cartilage degeneration after damage than intercarpal joints.

Prognostic Role of Measurement of Renal Resistive Index in Systemic Sclerosis

Objective:

The spectrum of vascular involvement in systemic sclerosis (SSc) includes digital ulcers, gangrene, Raynaud’s phenomenon, renovascular disease, and pulmonary hypertension (PH). Recognition of markers of subclinical vascular disease in SSc is an area of active research, but such studies are limited. This study assesses the role of measurement of the renal resistive index (RRI) as an early marker of renal and systemic vasculopathy. It is a step forward towards examining the possibility of a “unified vascular phenotype’ in SSc.

Methods:

In this single-centre prospective study, RRI was calculated for SSc patients >18 years age. Elevated RRI (>0.7) was correlated with renal function (eGFR and proteinuria) and systemic vasculopathy manifestations like digital ulcers, digital infarcts, and PH.

Results:

A total of 73 patients with mean (SD) age 41.8(10.9) years were included. Mean (SD) RRI in the right and left renal artery was 0.65(0.08) and 0.66(0.07), respectively. 16 (21.9%) patients had elevated RRI (>0.7). A strong negative correlation was noted between elevated RRI and eGFR (r= −0.96, p=0.03). The percentage of patients with overt proteinuria was higher in the group with elevated RRI (20% versus 7%) (p=0.16). Similarly, digital ulcers (56% vs 33%) and digital pitting (50% vs 35%.) were numerically higher in the group with raised RRI, although statistical significance was not reached because of small numbers (p=0.09 and 0.28, respectively). No correlation of RRI with PH was identified.

Conclusion:

RRI correlates well with asymptomatic renal dysfunction and holds promise in the assessment of systemic vasculopathy. However, validation in studies with a larger sample size is needed.

Combining Platelet-Rich Plasma Instillation With Core Decompression Improves Functional Outcome and Delays Progression in Early-Stage Avascular Necrosis of Femoral Head: a 4.5- to 6-Year Prospective Randomized Comparative Study

BACKGROUND

Avascular necrosis of femoral head is a debilitating disease frequently progressing to femoral head collapse and joint destruction. The efficacy of core decompression (CD) remains controversial.

METHODS

About 40 consecutive age-matched and gender-matched patients (53 hips) were randomized into 2 groups by computer-generated algorithm table in a prospective randomized double-blinded comparative study. Group A (platelet-rich plasma [PRP] with CD) included 19 patients (25 hips), and group B (CD only) included 21 patients (28 hips). Postoperative Harris Hip Score and magnetic resonance imaging to quantify the necrotic area by using modified Kerboul angle were done and evaluated. Mean follow-up was 64.3 months (range, 54-72) and 63.7 months (range, 56-72) in groups A and B, respectively.

RESULTS

There was statistically significant difference between PRP and control groups in pain score (P = .00), functional score (P = .02), and Harris Hip Score (P = .00) at final follow-up. There was no progression in stage 1 disease. Stage 2 disease showed 24% progression in group A and 43% progression in group B. The difference was statistically significant (P = .025). Survivorship from femoral head collapse, any procedure, and total hip arthroplasty was 84%/68% (P = .00), 76%/57% (P = .02), and 92%/78% (P = .01) in 2 groups, which was statistically significant.

CONCLUSION

PRP use after CD provides significant pain relief, better midterm functional outcome, retards the progression, and enhances the survivorship free from reoperation for hip arthroplasty and femoral head collapse in early stages of avascular necrosis of hip than CD alone.

Structured Optimal Graph-Based Clustering With Flexible Embedding

In the real world, the duality of high-dimensional data is widespread. The coclustering method has been widely used because they can exploit the co-occurring structure between samples and features. In fact, most of the existing coclustering methods cluster the graphs in the original data matrix. However, these methods fail to output an affinity graph with an explicit cluster structure and still call for the postprocessing step to obtain the final clustering results. In addition, these methods are difficult to find a good projection direction to complete the clustering task on high-dimensional data. In this article, we modify the flexible manifold embedding theory and embed it into the bipartite spectral graph partition. Then, we propose a new method called structured optimal graph-based clustering with flexible embedding (SOGFE). The SOGFE method can learn an affinity graph with an optimal and explicit clustering structure and does not require any postprocessing step. Additionally, the SOGFE method can learn a suitable projection direction to map high-dimensional data to a low-dimensional subspace. We perform extensive experiments on two synthetic data sets and seven benchmark data sets. The experimental results verify the superiority, robustness, and good projection direction selection ability of our proposed method.

Cytomorphometric Study of Changes in Buccal Mucosal Cells in Alcoholics

Background:

Chronic alcohol consumption carries a high risk for oral and pharyngeal cancers among persons who have never smoked. Excessive alcohol consumption displays cytogenetic changes in oral mucosa cells. Cytomorphometric analysis of oral mucosal cells helps in the early detection of cytomorphological transformations in alcoholics before and after the onset of carcinoma.

Materials and Methods:

A prospective, hospital-based, comparative study was done after written informed consent. Smears were obtained from the clinically normal buccal mucosa of 102 randomly selected alcoholic patients attending the medicine outpatient department aged above 25 years who consumed a minimum of 45 ml alcohol per day for at least 10 years and of 102 nonalcoholics as control. The slides were immediately fixed in absolute methanol and stained by the Papanicolaou (Pap) staining technique. PAP-stained smears were examined under the light microscope. Using the image J 1.47 image analysis software, a morphometric analysis of around 50 cells/case was done.

Results:

A statistically significant increase in mean cytoplasmic area (P < 0.001), mean nuclear area (P < 0.01), and cell-to-nuclear parameter ratio (P < 0.001) was seen in the alcohol group in comparison with the control group.

Conclusion:

Prolonged consumption of alcohol produces cytomorphometric changes in buccal mucosal cells before the onset of premalignant lesions.

Patellar Osteoid Osteoma as a Cause of Intractable Anterior Knee Pain - A Case Report and Systematic Review of Literature

Introduction:

Patellar involvement by osteoid osteoma is very rare. Osteoid osteomas that present as anterior knee pain are frequently misdiagnosed which leads to initial delay in treatment. Plain radiology has poor diagnostic yield. A combination of high index of suspicion, appropriate imaging, and complete ablation of the lesion is necessary to achieve good outcomes.

Case Report:

A 16-year-old male presented with insidious onset anterior knee pain for the past 2 years. The pain was intermittent and mild; however, it increased progressively in intensity and frequency, which was worse at night. Examination reveals minimal effusion in the suprapatellar pouch, full range of motion of the knee, and wasting of the quadriceps. Serum biochemistry parameters were in normal limits. Plain radiographs did not reveal any significant abnormality. On magnetic resonance imaging, a hypointense, punctate lesion surrounded by a small hyperintense zone was noted at medial aspect of patella. A computed tomography scan showed the lesion with a central nidus, surrounded by a sclerotic rim, confirming the diagnosis of osteoid osteoma. Radiofrequency ablation was carried out without any post-procedural complications. The patient was pain free a few days after the procedure. At 14-month follow-up, there was no recurrence of symptoms.

Conclusion:

Osteoid osteomas that present as anterior knee pain are frequently misdiagnosed. Plain radiology has poor diagnostic yield. A combination of high index of suspicion, appropriate imaging, and complete ablation of the lesion is necessary to achieve good outcomes.