Four-year overall survival update from the phase III HIMALAYA study of tremelimumab plus durvalumab in unresectable hepatocellular carcinoma

BACKGROUND

In the phase III HIMALAYA study (NCT03298451) in unresectable hepatocellular carcinoma (uHCC), STRIDE (Single Tremelimumab Regular Interval Durvalumab) significantly improved overall survival (OS) versus sorafenib; durvalumab monotherapy was noninferior to sorafenib for OS. Results reported herein are from a 4-year updated OS analysis of HIMALAYA.

PATIENTS AND METHODS

Participants with uHCC and no previous systemic treatment were randomized to STRIDE (n = 393), durvalumab (n = 389), or sorafenib (n = 389). The updated data cut-off was 23 January 2023. OS and serious adverse events (AEs) were assessed. Additionally, baseline characteristics and subsequent therapies were analyzed in long-term survivors (≥36 months beyond randomization).

RESULTS

For STRIDE, durvalumab, and sorafenib, median [95% confidence interval (CI)] follow-up was 49.12 months (46.95-50.17 months), 48.46 months (46.82-49.81 months), and 47.31 months (45.08-49.15 months), respectively. OS hazard ratio (95% CI) for STRIDE versus sorafenib was 0.78 (0.67-0.92). The 36-month OS rate for STRIDE was 30.7% versus 19.8% for sorafenib. The 48-month OS rate remained higher for STRIDE at 25.2%, versus 15.1% for sorafenib. The long-term OS benefit of STRIDE was observed across clinically relevant subgroups and was further improved in participants who achieved disease control. Long-term survivors with STRIDE (n = 103) included participants across clinically relevant subgroups, and 57.3% (59/103) had no reported subsequent anticancer therapy. No new serious treatment-related AEs occurred with STRIDE from the primary analysis (17.5%; 68/388). Durvalumab maintained OS noninferiority to sorafenib and no late-onset safety signals were identified.

CONCLUSIONS

These data represent the longest follow-up to date in phase III studies in uHCC. The unprecedented 3- and 4-year OS rates reinforce the sustained long-term OS benefit of STRIDE versus sorafenib. STRIDE maintained a tolerable yet differentiated safety profile from other current uHCC therapies. Results continue to support the long-term benefits of STRIDE in a diverse population, reflective of uHCC globally.

Correlation of age with the size of subcortical nuclei of the brain and its implication in degenerative disease: A magnetic resonance imaging study

Background

Aging is a non-modifiable risk factor for neurodegenerative disease. It is well established that the brain undergoes physiological atrophy with age. So, this study was conducted to analyse the correlation between the age of the person and the size of the various subcortical nuclei of the brain and whether these measurements can serve as a useful indicator for physiological atrophy leading to degenerative disease in clinical practice.

Methods

A total of 600 MRI scans from healthy individuals were examined and the measurements of subcortical nuclei were taken and subsequently analysed.

Results

A statistically significant difference between the genders was observed in the sizes of the axial diameters of caudate nucleus, putamen and globus pallidus. Caudate nucleus transverse diameter showed a moderate negative correlation with age in males. Globus pallidus axial diameter with age showed weak positive correlation for males. Globus pallidus transverse diameter showed weak positive correlation with age for both males and females, but it was stronger for males compared to females.

Conclusions

These results will help neurologists and neurosurgeons in analysing various early degenerative diseases and treat them accordingly.

Morphometric measurements of mandible to determine stature and sex: A postmortem study

Objectives

Identification of humans has medicolegal relevance in civil issues involving property inheritance, marriage, contested sex, admission to educational institutions, and the disappearance of individuals. To determine the sex of human remains, forensic anthropologists usually use morphologic and metric approaches. This study was conducted to determine stature and sex according to mandibular dimensions in postmortem autopsy samples.

Methods

A total of 150 mandibles from people 18-65 years of age were studied. Stature and sex were noted, and six mandibular measurements were taken with Vernier calipers, flexible measuring tape, a protractor, and a graduated autopsy table. Statistical analysis of the measured parameters was conducted in SPSS software. Statistical parameters, such as mean, standard deviation, Spearman's correlation coefficient, multiple linear regression, stepwise regression, and Mann-Whitney U test were analyzed.

Results

Bicondylar width was the stature estimation predictor with the strongest correlation (r = 0.439). The other parameters significantly associated with stature were bigonial width (p = 0.000), mandibular angle (p = 0.004), and mandibular arch length (p = 0.000), according to Spearman's correlation coefficient. The mandibular angle had the greatest dimorphic statistical significance (p = 0.004) according to the Mann-Whitney U test.

Conclusion

Bicondylar width may serve as a valuable tool for estimating stature, and mandibular angle can be used to identify sex. Our findings may help forensic anthropologists estimate stature and identify human remains.

A Morphological Study Of The Sensory Innervation Of Hand In South India With Its Clinical Implications

INTRODUCTION

The sensory innervation of the hand is getting a lot of attention because of the quick surge in the usage of local anesthesia and the progress of plastic surgeries. It is significant to know the likely disparities in the sensory innervation of the hand to prevent mistakes while analyzing the symptoms or misdiagnosing the nerve pathology. So this study aims to assess the sensory innervation of the hand.

MATERIALS AND METHOD

The study was carried out on 54 upper limbs. All the branches of the median, ulnar and radial nerve were traced. Variations in the distribution and anastomoses were noted.

RESULTS

Anastomosis between the median and ulnar nerve was found in 12.95% of cases. In all cadavers, 3 1⁄2 digits are supplied by the median nerve and 1 1⁄2 digits by the ulnar nerve bilaterally in the palms. In all cadavers 2 1⁄2 digits, each is supplied by radial and ulnar nerve bilaterally on the dorsum of hands.

CONCLUSION

These anatomic conclusions will aid hand surgeons in identifying differences in sensory losses after either dorsal or palmar injuries.

Assessment of prevalence of dry eye among medical students using ocular surface disease index questionnaire - Is COVID-19 to be really blamed?

Purpose

An undergraduate research conducted during the pre-covid times, to highlight the importance of screen time and its association with dry eye in medical students. The aim was to study the prevalence of dry eye among medical students using the ocular surface index (OSDI) questionnaire.

Methods

This was a cross-sectional study. This study was conducted among medical students using an OSDI questionnaire in the pre-covid times. Based on the pilot study, the minimum sample size calculated was 245. A total of 310 medical students participated in the study. These medical students answered the OSDI questionnaire. The OSDI score was used to categorize students with dry eye as mild (13-22 points), moderate (23-32 points), and severe (33-100 points). In addition, the associations between the OSDI score and possible risk factors such as gender, contact lens/spectacle wear, laptop/mobile usage, and duration of exposure to air conditioners were also studied.

Results

The analysis of the study revealed that out of 310 students, dry eye was seen in 143 (46.1%) and severe dry eyes were seen in 50 (16.1%). A high OSDI score (>13 points) was associated with the usage of a laptop/mobile for more than 6 h in 40 (52.6%) (P < 0.001).

Conclusion

The prevalence of dry eye among medical students was 46.1% in the present study. Longer duration of usage of visual display units (laptop/mobile) was the only factor that showed a statistically significant association with dry eye in our study.

Surgical anatomy of hypoglossal canal for various skull base surgeries

PURPOSE

Anatomical knowledge of the hypoglossal canal is very important in relation to drilling of occipital condyle, jugular tubercle etc. So, this study was conducted to identify various morphometric and morphological features of the hypoglossal canal and its distance from adjacent structures relative to stable and reliable anatomic landmarks.

METHODS

The study was performed on 142 hypoglossal canals of 71 adult human dry skulls. The parameters measured were the transverse, vertical diameter, depth of the hypoglossal canal. The distances from the hypoglossal canal to the foramen magnum, occipital condyle and jugular foramen were also noted. In addition, the different locations of the hypoglossal canal orifices in relation to the occipital condyle were assessed. The different shapes and types of the hypoglossal canal were also noted.

RESULTS

There was significant difference (p < 0.05) in measurements taken on the right and left sides in males and females. The intracranial orifice of hypoglossal canal was present in middle 1/3rd in 100% of occipital condyle for both genders. The extracranial orifice of the hypoglossal canal was found to be in the anterior 1/3rd in 99% and 93.7% for male and female, respectively. Simple hypoglossal canal with no traces of partition was found to be more in males and females. The most common shape noted was oval both in males and females (71.8% and 68.7% respectively).

CONCLUSION

The results of the dimensions of the hypoglossal canal and its distance from other bony landmarks will be helpful for neurosurgeons to plan which surgical approaches should be undertaken while doing various surgeries in posterior cranial fossa.

Undernutrition and associated factors among lactating mothers in Dehradun, Uttarakhand, India

Undernutrition was one of the most widespread public health problems that affected both developed and developing countries. In India, it was one of the factors which lead to unacceptably high morbidity and mortality among women. However, little was documented on undernutrition among lactating women, particularly in the urban community. This study aimed to evaluate the nutritional status and its related factors among lactating mothers in the urban areas of the Dehradun region, Uttarakhand, India. A structured, pre-tested, and validated questionnaire was used to capture the sociodemographic information including the economical and medical conditions of 150 lactating women in Dehradun, India. Pearson correlation coefficient and association of various factors determined that 31.33% of women were in the age bracket of 20-25 years and the low-income group (72%). The prevalence of underweight was 7.33%, and the mean and standard deviation of the body mass index of mothers were 20.59±2.96 and 21.70±3.18 for sedentary and moderate workers respectively. There were significant correlations found between BMI, energy, carbohydrates, and fat intake (p<0.05). A multivariate regression model was used to associate the nutritional status of the participant’s income group, education, type of work, age of mothers, and frequency of meals. Based on the results, intervention programs for dietary correction and the effect of nutrition on the body were emphasized to lactating mothers for better health and nutritional outcomes.

Morphological study on distribution of nutrient foramina in femoral neck in relation to retinacula of weitbrecht with its surgical implications

Background

Now a day's many surgeries are done around the head and neck of femur like femoral head resurfacing arthroplasty for managing advanced hip-joint degeneration. Thus, it is vital for an orthopaedic surgeon to exactly understand the vascular supply of the neck of femur. The knowledge of distribution of foramina and their relation to the retinacula of Weitbrecht will help orthopaedic surgeons to choose their management technique for various injuries. So, this study was undertaken to study the number, size and distribution of nutrient foramina in all the surfaces of neck of femur and their relations to the retinacula of Weitbrecht.

Materials and method

Study was conducted on 200 adult dry femora. The retinacula of Weitbrecht are first defined later the subcapital, transcervical and basicervical regions of the femoral neck are marked. The number of foramina, size and their distribution in relations to the retinacula of Weitbrecht were observed. Later the results were analyzed statistically.

Results

40.01% of foramina were observed in the subcapital region, 31.74% in basicervical and 28.24% were noted in transcervical region. The nutrient foraminal density was significantly higher in the upper retinacula (57.03%), followed by anterior retinacula (27.3%) and least in the region of inferior retinacula (15.66%). It was observed that most foramina were less than 1 mm diameter followed by 1-2 mm diameter foramina.

Conclusion

This knowledge of foraminal distribution in femoral neck will be helpful in surgeries involving the hip joint and femoral head & neck fractures.

Long-term Results of Nd:YAG Goniopuncture on Viscocanalostomy and Phacoviscocanalostomy

PRCIS

Laser goniopuncture (LGP) is an effective outpatient procedure which has been shown to maintain reduced intraocular pressure (IOP) 5 years following initial laser treatment in patients who have had viscocanalostomy (VC) (with or without phacoemulsification).

PURPOSE

The purpose of this study was to establish the long term (5 y) efficacy of neodymium-doped:yttrium aluminum-garnet LGP to lower IOP following VC or phacoviscocanalostomy (PVC) in patients with glaucoma.

PATIENTS AND METHODS

This retrospective study analyzed patients who underwent LGP following VC±phacoemulsification between 2009 and 2012 at the Stanley Eye Unit in Abergele. Reason for further intervention included either increasing IOP outside target range or worsening visual fields. Statistical analyses were performed comparing pregoniopucture values to those taken up to 5 years later.

RESULTS

Of the 620 VC and PVC procedures performed between 2009 and 2012, 218 eyes underwent LGP after a mean of 25 months [95% confidence interval (CI): 22.58 to 27.41] following surgery. Patients having a PVC had a longer mean time to goniopuncture compared with those who were phakic and had VC only (P<0.001). Immediately following goniopuncture IOP dropped, and a statistically significant reduction persisted at 5 year follow-up (P<0.001). Goniopuncture reduced IOP significantly from a pretreatment value of 21 to 15 mm Hg over 5 years (95% CI) (χ2F(4)=119.1, P<0.001). In total, 154 eyes (71%) were commenced on IOP-lowering medication at a mean of 14 months (95% CI: 12 to 17). At 5 years, successful IOP control was achieved in 73% (49 of 67) of eyes. There was no difference found between type of surgery and successful pressure control at 5 years (χ2(1)=2.00, P=0.16).

CONCLUSION

LGP is an effective procedure which maintains a statistically significant reduction in IOP in the long term.

Utility of serum Galactomannan in diagnosing COVID-19 patients with suspected IPA: an observational study in resource limited settings

OBJECTIVE

To study the utility of Galactomannan (GM) antigen as a screening marker for diagnosing invasive pulmonary aspergillosis (IPA) in coronavirus disease 2019 (COVID-19) patients.

PATIENTS AND METHODS

The serum samples from patients with severe COVID-19 diseases admitted to the Critical Care Unit were collected on the 5th day of admission for GM screening. The samples were analysed by enzyme linked immune sorbent assay (ELISA) and GM index of more than 1 was considered as positive. All GM positive patients were serially followed until discharge or death.

RESULTS

The GM was raised in serum of 12 out of 38 patients, indicating an incidence of possible COVID-19 associated IPA (CAPA) in 31.57% of patients. The median age of these CAPA patients was 56.5 years, males were significantly more affected than females. The inflammatory marker serum ferritin was raised in all 12 patients (median value of 713.74 ng/ml), while IL-6 was raised in 9 patients (median value of 54.13 ng/ml). None of these patients received antifungals. Their median length of hospital stay was 20 days (IQR: 12, 34 days). All these patients succumbed to the illness.

CONCLUSIONS

The serum GM appears to be sensitive diagnostic tool to identify early IPA in COVID-19 patients and pre-emptive antifungal therapy could play a role in salvaging these patients.

Comparison of anthropometric measurements of foetuses in normal, gestational diabetes-affected, and hypertensive pregnancies

OBJECTIVES

Foetal anthropometry evaluates and monitors foetal development and assesses the nutritional state of the developing foetus. It is a vital indicator of the normalcy of foetal development in-utero. The most relevant parameters in foetal anthropometry are biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL). Gestational diabetes mellitus (GDM) and gestational hypertension (GHTN) are the major reasons for variations in foetal development. In this study, we compare foetal anthropometric measurements taken using ultrasounds of normal, gestational diabetes-affected, and hypertensive pregnancies.

METHOD

In this study, a total of 615 anomaly scans were done between the gestational ages of 18-22 weeks from 2016 to 2018. The patients' data were collected from the register of the anomaly scanning room. The foetal anthropometric parameters measured BPD, HC, AC, and FL.

RESULTS

All the measurements including BPD, HC, and AC were lower in foetuses affected by GHTN, and all the measurements, including FL, were higher in foetuses affected by GDM than in normal pregnancies. A post-hoc analysis using Tukey's test showed that each foetal parameter had a significant correlation with pregnancy-related co-morbidities (p-value < 0.05).

CONCLUSION

It is clear from our study that the foetuses of mothers with GDM showed a consistent variation of 10 mm above the normal average in terms of the BPD, HC, AC, and FL measurements. The GHTN-affected foetuses had averages that were lower than normal for BPD, HC, and AC.

Age-Related Histological Changes in Vena Caval System of Human Foetus and Adult: A Comparative Study

Background

It has been documented that cardiac musculature is present in both venae cavae, and they contract together with the atrium, contributing to the pumping mechanism of the heart. So, in the present study, we measured the relative thicknesses of the three histological layers at formation, termination and intermediate levels of the venae cavae along with their histological characteristics.

Materials and Methods

Ten foetal and 10 adult cadavers were used. The Superior and Inferior Venae Cavae from all three regions were excised and processed for histology. The qualitative and quantitative features of the vessels were observed and recorded. The data thus obtained was then assessed statistically.

Results

In superior vena cava, the tunica intima grows actively especially during late gestation. The tunica media shows active growth. The tunica adventitia growth is significant at the middle and termination levels. In inferior vena cava, the tunica intima grows actively at the level of formation. The tunica media shows the active overall growth during early gestation. The tunica adventitia shows active growth during late gestation. In qualitative analysis the plump, spindle-shaped primitive mesenchymal cells were observed. Muscle and collagen fibers show reciprocal abundance with increasing age, with the former being lesser in amount than the latter in earlier stages. Appearance of vasa vasorum was notable from 2nd trimester. The cardiac myocytes were located in the middle and outer tunics of the superior vena cava.

Conclusion

Cardiac musculature was absent in the inferior vena; however, the vessel shows advanced rate of overall development.

MRI-Derived Fetal Weight Estimation in the Midpregnancy Fetus: A Method Comparison Study

OBJECTIVES

The aim of this study was to compare the standard ultrasound (US) estimated fetal weight (EFW) and MRI volume-derived methods for the midtrimester fetus.

METHODS

Twenty-five paired US and MRI scans had the EFW calculated (gestational age [GA] range = 20-26 weeks). The intra- and interobserver variability of each method was assessed (2 operators/modality). A small sub-analysis was performed on 5 fetuses who were delivered preterm (mean GA 29 +3 weeks) and compared to the actual birthweight.

RESULTS

Two MRI volumetry EFW formulae under-measured compared to US by -10.9% and -14.5% in the midpregnancy fetus (p < 0.001) but had excellent intra- and interobserver agreement (intraclass correlation coefficient = 0.998 and 0.993). In the preterm fetus, the mean relative difference (MRD) between the MRI volume-derived EFW (MRI-EFW) and actual expected birthweight (at the scan GA) was -13.7% (-159.0 g, 95% CI: -341.7 to 23.7 g) and -17.1% (-204.6 g, 95% CI: -380.4 to -28.8 g), for the 2 MRI formulae. The MRD was smaller for US at 5.3% (69.8 g, 95% CI: -34.3 to 173.9).

CONCLUSIONS

MRI-EFW results should be interpreted with caution in midpregnancy. Despite excellent observer agreement with MRI volumetry, refinement of the EFW formula is needed in the second trimester, for the small and for the GA and preterm fetus to compensate for lower fetal densities.

Towards automated extraction of 2D standard fetal head planes from 3D ultrasound acquisitions: A clinical evaluation and quality assessment comparison

Introduction

Clinical evaluation of deep learning (DL) tools is essential to compliment technical accuracy metrics. This study assessed the image quality of standard fetal head planes automatically-extracted from three-dimensional (3D) ultrasound fetal head volumes using a customised DL-algorithm.

Methods

Two observers retrospectively reviewed standard fetal head planes against pre-defined image quality criteria. Forty-eight images (29 transventricular, 19 transcerebellar) were selected from 91 transabdominal fetal scans (mean gestational age = 26 completed weeks, range = 20⁺⁵–32⁺³ weeks). Each had two-dimensional (2D) manually-acquired (2D-MA), 3D operator-selected (3D-OS) and 3D-DL automatically-acquired (3D-DL) images. The proportion of adequate images from each plane and modality, and the number of inadequate images per plane was compared for each method. Inter and intra-observer agreement of overall image quality was calculated.

Results

Sixty-seven percent of 3D-OS and 3D-DL transventricular planes were adequate quality. Forty-five percent of 3D-OS and 55% of 3D-DL transcerebellar planes were adequate.

Seventy-one percent of 3D-OS and 86% of 3D-DL transventricular planes failed with poor visualisation of intra-cranial structures. Eighty-six percent of 3D-OS and 80% of 3D-DL transcerebellar planes failed due to inadequate visualisation of cerebellar hemispheres. Image quality was significantly different between 2D and 3D, however, no significant difference between 3D-modalities was demonstrated (p < 0.005). Inter-observer agreement of transventricular plane adequacy was moderate for both 3D-modalities, and weak for transcerebellar planes.

Conclusion

The 3D-DL algorithm can automatically extract standard fetal head planes from 3D-head volumes of comparable quality to operator-selected planes. Image quality in 3D is inferior to corresponding 2D planes, likely due to limitations with 3D-technology and acquisition technique.

Implications for practice

Automated image extraction of standard planes from US-volumes could facilitate use of 3DUS in clinical practice, however image quality is dependent on the volume acquisition technique.

A Morphometric Study of Stylomastoid Foramen with Its Clinical Applications

Background To prevent damage to the facial nerve while doing surgery and to give facial nerve block by anesthetics near the stylomastoid foramen we should know its distance from the important anatomical landmarks. So, this study aims to study the location of stylomastoid with respect to nearby anatomical landmarks.

Materials and Method The study was performed on 58 dry skulls. Measurements of stylomastoid foramen were taken from various anatomical landmarks on both sides of the skull. Data analysis was done by using the Statistical Package for Social Sciences (SPSS) 19 version.

Results The mean distance of the center of the stylomastoid foramen (CSMF) to the tip of the mastoid process was 1.60, 1.57 cm on the right and left side, respectively. The mean distance of CSMF to the upper end of the anterior border of the mastoid process was 1.42, 1.39 cm on the right and left side, respectively. The mean angle between CSMF and tip of the mastoid process was 51.6 degrees, 53.5 degrees on right and left side, respectively. The mean distance of CSMF to the center of jugular foramen was 1.27, 1.26 cm on the right and left side, respectively. The position of the stylomastoid foramen in relation to a transverse line passing through the upper end of the anterior border of both mastoid processes was anterior in 82.7%, 94.8% of cases on the right and left side, respectively.

Conclusion These measurements will aid neurosurgeons in doing surgeries near the stylomastoid foramen or anesthetics to give facial nerve block near the foramen.

The relationship between alertness and spatial attention under simulated shiftwork

Higher and lower levels of alertness typically lead to a leftward and rightward bias in attention, respectively. This relationship between alertness and spatial attention potentially has major implications for health and safety. The current study examined alertness and spatial attention under simulated shiftworking conditions. Nineteen healthy right-handed participants (M = 24.6 ± 5.3 years, 11 males) completed a seven-day laboratory based simulated shiftwork study. Measures of alertness (Stanford Sleepiness Scale and Psychomotor Vigilance Task) and spatial attention (Landmark Task and Detection Task) were assessed across the protocol. Detection Task performance revealed slower reaction times and higher omissions of peripheral (compared to central) stimuli, with lowered alertness; suggesting narrowed visuospatial attention and a slight left-sided neglect. There were no associations between alertness and spatial bias on the Landmark Task. Our findings provide tentative evidence for a slight neglect of the left side and a narrowing of attention with lowered alertness. The possibility that one’s ability to sufficiently react to information in the periphery and the left-side may be compromised under conditions of lowered alertness highlights the need for future research to better understand the relationship between spatial attention and alertness under shiftworking conditions.

Adiponectin in onset and progression of T2DM with cardiac dysfunction in rats

Cardiovascular disease and type 2 diabetes mellitus (T2DM) patients have low level of adiponectin, however, till now the role of adiponectin in progression of ‘T2DM with cardiac dysfunction’ in animal model has not been characterized. Therefore, the aim of the present study was to develop and characterize T2DM animal model with cardiac dysfunction and to study the role of cardiac adiponectin expression in cardiac dysfunction. For this, Wistar rats (M/F) were fed a high-fat diet for different time periods: 3, 4 and 5 weeks and given a single, low-dose streptozotocin (25mg/kg), intraperitoneal injection 1 week prior to the experiments. Rats in T2DM group (3 weeks) developed hyperglycaemia, hyperlipidaemia, oxidative stress with normoinsulinaemia and mild cardiac dysfunction suggesting onset of T2DM with cardiac dysfunction. Extended high-fat feeding, that is, 4 and 5 weeks induced insulin resistance accompanied with cardiac hypertrophy, cardiac dysfunction and reduced baroreflex sensitivity indicating development of T2DM with cardiac dysfunction. Cardiac adiponectin expression did not change in rats of T2DM group (3 weeks), however, it significantly decreased in rats of two T2DM groups (4 and 5 weeks) along with increased intracellular adhesion molecule-1 levels. Thus, the present study for the first time indicates that in the present T2DM animal model, as T2DM progresses cardiac adiponectin expression also decreases which might be the precipitating factor for cardiac hypertrophy and decrease in baroreflex sensitivity, which induces cardiac dysfunction.

Histogenesis and Histomorphometric study of Human Fetal Small Intestine

Background

Intestine plays a major role for the normal growth of the fetus during the prenatal period. The process of the embryonic development is not quantified histologically. Therefore the main aim of the study was to measure the thickness of all part of the wall of the small intestine that are mucosa, submucosa and muscularis externa and to look for the appearance of the Brunner's glands and Peyer's patches in the submucosa of duodenum and ileum.

Methods

The present study was carried out on 30 fetuses of gestational ages ranging from 11–36 weeks. Ten fetuses from each trimester were used in the study. Fetal small intestine were dissected carefully, and were separated as duodenum, jejunum & ileum and fixed in formalin solution. The tissue was processed for histology and then slides were stained with Haematoxylin and Eosin. The microscopic features were noted using light microscope.

Results

The thickness of the mucosa, submucosa and the muscularis externa was observed to be increased in first trimester, decreased in the second trimester and again increased in the third trimester, which could be because of the increase cell turnover and the arrangement of the collagen fibers as to support the mucosa and the muscularis externa.

Conclusion

Thus, the knowledge of the histogenesis and histomorphometry of the human fetal small intestine is crucial for the adult gastroenterologist to appreciate, because of the potential for these early life events to affect the responsiveness of the intestine to physiological or pathological challenges in later life.

XEN® stent complications: a case series

Background

XEN® gel stent (Allergan, Dublin/Republic of Ireland) is a relatively new microinvasive glaucoma device providing an ab-interno approach to the subconjunctival space for aqueous drainage and reduction of intraocular pressure. It is thought to be less invasive, reduce surgical time and post-operative infection rates compared with traditional glaucoma procedures. Little information however, has been published regarding complications and subsequent management.

Case presentation

The authors highlight five complicated cases of XEN® stent insertion, how they were managed and key learning points. Cases include: entire stent found at the bottom of the anterior chamber several months after uncomplicated insertion, stent broke into multiple pieces during manipulation within subconjunctiva, XEN45 stent migrated into the anterior chamber 7 months post-operatively and a case of limbal-based conjunctival dissection during open revision which lead to additional scarring around the stent and subsequent raised intraocular pressure.

Conclusions

We present some new and interesting complications of XEN implant as well as potential management options. This can assist clinical decision-making and enable better pre-operative discussions with patients regarding risks of surgery.

Fetal Skull Reconstruction via Deep Convolutional Autoencoders

Ultrasound (US) imaging is arguably the most commonly used modality for fetal screening. Recently, 3DUS has been progressively adopted in modern obstetric practice, showing promising diagnosis capabilities, and alleviating many of the inherent limitations of traditional 2DUS, such as subjectivity and operator dependence. However, the involuntary movements of the fetus, and the difficulty for the operator to inspect the entire volume in real-time can hinder the acquisition of the entire region of interest. In this paper, we present two deep convolutional architectures for the reconstruction of the fetal skull in partially occluded 3DUS volumes: a TL deep convolutional network (TL-Net), and a conditional variational autoencoder (CVAE). The performance of the two networks was evaluated for occlusion rates up to 50%, both showing accurate results even when only 60% of the skull is included in the US volume (Dice coeff. $0.84\pm 0.04$ for CVAE and $0.83\pm 0.03$ for TL-Net). The reconstruction networks proposed here have the potential to optimize image acquisition protocols in obstetric sonography, reducing the acquisition time and providing comprehensive anatomical information even from partially occluded images.

Endophthalmitis Following XEN Stent Exposure

BACKROUND

XEN45 Gel stents are in their infancy, and clinical expertise with microsurgical glaucoma devices are increasing. The soft flexible nature of the XEN stent together with its malleability under the conjunctival tissue should negate any risk of exposure of the XEN45 stent (XEN). However, we report a case in which sight-threatening endophthalmitis was the presenting feature of this complication.

CASE REPORT

We present a case of uncomplicated XEN implantation that developed endophthalmitis 4 months after surgery. She gave an 8-day history of diarrhea before presentation. She was noted to have exposure of the XEN stent at the point of entry of the XEN into the subconjunctival space. The stent was removed, pars plana vitrectomy was carried out, and intravitreal antibiotics were administered. Achieving low intraocular pressures, bearing in mind her preservative allergy, became a challenge, as we struggled to manage her advanced glaucoma medically. A CyPass Micro-Stent was subsequently inserted to control the intraocular pressure.

CONCLUSIONS

Episodes of XEN stent exposure may not be so isolated. We postulate that poor handwashing transmitted the causative organism to the exposed stent, which then resulted in endopthalmitis. We would like to highlight a few learning points from this case.

Fast Multiple Landmark Localisation Using a Patch-based Iterative Network

We propose a new Patch-based Iterative Network (PIN) for fast and accurate landmark localisation in 3D medical volumes. PIN utilises a Convolutional Neural Network (CNN) to learn the spatial relationship between an image patch and anatomical landmark positions. During inference, patches are repeatedly passed to the CNN until the estimated landmark position converges to the true landmark location. PIN is computationally efficient since the inference stage only selectively samples a small number of patches in an iterative fashion rather than a dense sampling at every location in the volume. Our approach adopts a multitask learning framework that combines regression and classification to improve localisation accuracy. We extend PIN to localise multiple landmarks by using principal component analysis, which models the global anatomical relationships between landmarks. We have evaluated PIN using 72 3D ultrasound images from fetal screening examinations. PIN achieves quantitatively an average landmark localisation error of 5.59mm and a runtime of 0.44s to predict 10 landmarks per volume. Qualitatively, anatomical 2D standard scan planes derived from the predicted landmark locations are visually similar to the clinical ground truth.

Morphometric analysis of infraorbital foramen in South Indian dry skulls

Objective- The infraorbital foramen is located on the maxillary bone 1 cm under the infraorbital margin. Infra orbital nerve blocks are done in children for managing the postoperative pain which can occur after cleft lip operation and endoscopic sinus operation. Infraorbital nerve can also be damaged in cases of zygomatic complex fractures which are one of the most common facial injuries. So, this study was undertaken to analyze the anatomical variations by comparing various morphometric measurements of infraorbital foramen in dry skulls of adult South Indian population.Materials and methods- 60 dry skulls of unknown sex were used for the study. Various measurements and distance from various surgical landmarks were measured to evaluate the location of infraorbital foramen on both sides. Statistical Analysis was done for the above measurements mean and standard deviation, median, range, and mode were calculated.Results: The mean distance of infraorbital foramen from piriform aperture, lower end of alveolus of maxilla and infraorbital margin was 18.39, 27.88 and 7.09mm on the right and 17.89, 27.31 and 6.95mm on the left side. The mean vertical and horizontal diameter was 3.78 and 3.50mm on the right side and 3.48 and 3.35mm on the left side. In our study, the most common site of IOF in Indian skulls was found to be in line with the second premolar tooth (59.01%), followed by its position between the first and second premolar tooth (27.87%).Conclusion- These results will be helpful for surgeons while doing maxillofacial surgery and regional block anesthesia.Bangladesh Journal of Medical Science Vol.17(4) 2018 p.562-566

Morphometric Study of Dorsalis Pedis Artery and Variation in its Branching Pattern: A Cadaveric Study

Introduction: Dorsalis pedis artery (DPA) is the chief artery that supplies the dorsum of the foot. Palpation of DPA at the dorsum of the foot is important in case of atherosclerotic disease. A sound knowledge of DPA like its branching pattern is essential for the ankle surgeries as well as its presence or absence in case of peripheral vascular disease. Material and methods: 30 Lower limbs of unknown age and sex were dissected in the department of Anatomy, Kasturba Medical College, Manipal. The skin and fascia were removed.The measurement of Dorsalis pedis artery till its termination, Length from medial malleolus, Length from lateral malleolus and branching pattern of Dorsalis pedis artery was studied. Results: In this study, the average length of dorsalis pedis artery was found 7.8cm, average length from medial malleolus was 3.9cm and average length from lateral malleolus was 4.5cm.The normal branching pattern of medial tarsal artery was noticed in 53% and lateral tarsal artery in 63% cases. The arcuate artery was absent in 3% of cases. Conclusion: The knowledge of the variation of DPA is helpful during various foot surgeries. Knowledge of the variation will be useful in deciding whether the absence of the pulse in DPA is due to thrombosis of the vessel or its abnormal course or absence. DPA does not always lie at mid -malleolar point.

Challenges in culture-negative cases of Madurella mycetomatis: A case report re-accentuating PCR as an essential diagnostic tool

Identification of dematiaceous fungi responsible for black-grain mycetoma has remained cumbersome and time consuming for years leading to delayed diagnosis and thereby increased agony to patients. Moreover, difficult morphology of some of these fungi demanding enough expertise for species identification in addition to culture-negativity has often led to misdiagnosis and hence inapt treatment to the patients. We report the identification of Madurella mycetomatis from culture-negative black granules discharged from foot nodular lesions of a 27 years old male using PCR followed by sequencing of the internal transcribed spacer region. The patient's lesions were successfully treated using a combination of itraconazole (200mg) and terbinafine (250mg), confirming our diagnosis. Our case study proves the clinical value of PCR as the best, rapid and accurate diagnostic method for the identification of Madurella mycetomatis and related fungi, particularly in culture-negative cases.

Dietary beliefs among informal caregivers regarding common childhood diseases in rural north-west India

Background: Dietary practices among infants and children are predictor of their growth and development. India being a huge of diverse cultures, diversity in beliefs and practices regarding diet during childhood illnesses is expected. Harmful beliefs and practices can contribute to malnutrition among children. These beliefs can have adverse consequences in already sick children. Aims and Objectives: To assess the dietary knowledge, beliefs and practices of rural care givers during childhood illnesses. Material & Methods: This cross-sectional descriptive study was conducted among 271 rural informal (parent / family member) caregivers in one of the sub-health centres which was selected using simple random sampling technique. In the context of this study, the word informal care-giver was used for parent/family member of the child, preferably a mother with a child / children aged less than five years. The survey tool was an open ended and pretested questionnaire which was developed by public health expert’s familiar with the culture of the study setting and was pilot tested before administration. For the purpose of recruiting the study participants a house to house survey was conducted and the data thus collected was analyzed in percentages. Results: Informal Caregivers had low knowledge of common childhood illnesses as well as the reasons of their causation. Majority of them consulted a doctor in the event of child’s illness. 53.81% reduced feeding and 31.93% diluted diet during child’ illness but significantly 77.85% didn’t change breastfeeding practice during illness. As far as the beliefs regarding dietary practices were concerned, it found that egg, meat, chicken and jaggery were labelled hot foods while curd, butter milk and vegetables were labelled as cold foods. Rice water and khichadi were preferred in diarrhoea but spicy food and milk were restricted. Ginger and Tulsi tea were preferred in respiratory infections while ice-cream and curd / milk were withheld. Conclusion: Hot and cold beliefs regarding foods are firmly rooted in the study population, so dietary education has a key role to play but it has to be within socio-cultural milieu of the people. It is imperative to train medical and para-medical staff in nutrition curriculum to promote healthy eating habits in the population

A morphological and morphometric study of proximal and distal ends of dry radii with its clinical implications

BACKGROUND

Knowledge of the size and shape of radial head is essential for construction of radial head prosthesis. Further, the measurements of bicipital tuberosity and its angular relationship to radial head are significant in surgical techniques, like in the reconstruction of biceps tendon. Even the morphometry of the distal radius is significant in numerous clinical orthopedic situations such as reduction of distal radius fractures and in the design of distal radius prosthesis. So, the aim of the study was to determine the morphometric parameters of proximal and distal radius in dry adult Indian radius.

METHODS

Fifty intact adult Indian radius (right = 23, left = 27) were chosen, and the various parameters of proximal and distal ends of radius were studied. Student's t-test was done to correlate all these parameters on the right and left sides.

RESULTS

The mean length of radius, height of head at medial and lateral ends, head anteroposterior and transverse diameter, head thickness at ventral, dorsal, and lateral ends were 23.5, 0.90, 0.75, 1.91, 1.85, 0.42, 0.32, and 0.30 cm, respectively. The mean depth of articular facet, length of neck, proximal and distal neck diameter, width and length of bicipital tuberosity, and radial circumference at bicipital tuberosity were 0.19, 1.19, 1.36, 1.31, 1.23, 1.97, and 4.54 cm, respectively. The mean length of styloid process, oblique and transverse width of lower end, anteroposterior diameter of lower end, and angle of radial inclination were 0.98cm, 2. 81cm, 2.59cm, 1.86cm, and 25.05°, respectively.

CONCLUSION

This study will be useful for orthopedic surgeons in making prosthesis for the proximal and distal ends of radius.

A morphological and morphometric study of jugular foramen in dry skulls with its clinical implications

OBJECTIVE

Jugular foramen of human skull is one of the most interesting foramina. It is a complex bony canal, numerous vital structures, including nerves and vessels are transmitted through it. Most of the intracranial and extra cranial lesions of posterior cranial fossa might affect the structures in jugular foramen in addition to intrinsic abnormalities. As the neurosurgeons have become courageous in approaching this area, so there is a need to become familiar with this area. Hence, the present study was done to examine the anatomy of jugular foramen, including its morphological features and dimensions.

MATERIALS AND METHODS

The study was carried out on 50 dried skulls. 100 jugular foramina were studied on both right and left side of skulls. The length, width of jugular foramen and width and depth of jugular fossa were measured using vernier calipers. Presence of dome, complete and incomplete septation was also looked for.

RESULTS

The mean right and left anteroposterior diameter, latero-medial diameter, area, jugular fossa width, depth in our study was 11.22, 16.52, 187.34, 6.83, 11.58 mm and 9.52, 16.02, 153.2, 5.69, 11.13 mm. Dome was present in jugular foramen in 74% on the right side and 58% on the left side. Complete septation in jugular foramen is seen in 44% on the right side and 42% on the left side.

CONCLUSION

This study will help the neurosurgeons while doing surgery in this region.

Anatomic study of the occipital condyle and its surgical implications in transcondylar approach

Background:

Craniovertebral surgeries require the anatomical knowledge of craniovertebral junction. The human occipital condyle (OC) is unique bony structure connecting the cranium and the vertebral column. A lateral approach like transcondylar approach (TA) requires understanding of the relationships between the OC, jugular tubercle, and hypoglossal canal. Hence, the aim of the present study was to analyze the morphological variations in OCs of dry adult human skull.

Materials and Methods:

The study was carried out on 142 OC of 71 adult human dry skulls (55 males and 16 females). Morphometric parameters such as length, width, thickness, intercondylar distances, and the distances from the OC to the foramen magnum, hypoglossal canal and jugular foramen were measured. In addition, the different locations of the hypoglossal canal orifices in relation to the OC and different shapes of the OC were also noted.

Results:

The average length, width and height of the OC were found to be 2.2, 1.1 and 0.9 cm. The anterior and posterior intercondylar distances were 2.1 and 3.9 cm, respectively. Maximum and minimum bicondylar distances were 4.5 and 2.6 cm, respectively. The intra-cranial orifice of the hypoglossal canal was found to be present in middle 1/3^rd in all skulls (100%), and extra-cranial orifice of the hypoglossal canal was found to be in anterior 1/3^rd (98%) in relation to OC. The oval shaped OC (22.5%) was the most predominant type of OC observed in these skulls.

Conclusion:

Occipital condyle is likely to have variations with respect to shape, length, width and its orientation. Therefore, knowledge of the variations in OC along with careful radiological analysis may help in safe TAs during skull base surgery.

Subcutaneous mycoses caused by Rhytidhysteron species in an immunocompetent patient

Subcutaneous mycoses are chronic fungal infections of the skin and subcutaneous tissues caused by variety of fungal agents and usually occur following trauma with vegetative matter. We report a case of subcutaneous mycoses caused by rare fungus belonging to the genus Rhytidhysteron, in an immunocompetent male who presented with a subcutaneous nodule on left foot. This unusual species was identified and confirmed by molecular methods.

Depletion of cells and abundant proteins from biological samples by enhanced dielectrophoresis

Platforms that are sensitive and specific enough to assay low-abundance protein biomarkers, in a high throughput multiplex format, within a complex biological fluid specimen, are necessary to enable protein biomarker based diagnostics for diseases such as cancer. The signal from an assay for a low-abundance protein biomarker in a biological fluid sample like blood is typically buried in a background that arises from the presence of blood cells and from high-abundance proteins that make up 90% of the assayed protein mass. We present an automated on-chip platform for the depletion of cells and highly abundant serum proteins in blood. Our platform consists of two components, the first of which is a microfluidic mixer that mixes beads containing antibodies against the highly abundant proteins in the whole blood. This complex mixture (consisting of beads, cells, and serum proteins) is then injected into the second component of our microfluidic platform, which comprises a filter trench to capture all the cells and the beads. The size-based trapping of the cells and beads into the filter trench is significantly enhanced by leveraging additional negative dielectrophoretic forces to push the micron sized particles (cells and beads which have captured the highly abundant proteins) down into the trench, allowing the serum proteins of lower abundance to flow through. In general, dielectrophoresis using bare electrodes is incapable of producing forces beyond the low piconewton range that tend to be insufficient for separation applications. However, by using electrodes passivated with atomic layer deposition, we demonstrate the application of enhanced negative DEP electrodes together with size-based flltration induced by the filter trench, to deplete 100% of the micron sized particles in the mixture.