Estimation of body density and lean body weight from body measurements at high altitude

Body density and other anthropometric data were obtained on 101 Indian soldiers who were continously staying at high altitude (3920 m) for more than 10 months. Use was made of a human body volumeter, and body density was calculated from observed body weight and volume. Measurements were taken on the body using standard techniques. A stepwise linear regression analysis was performed to establish possible relationships of 36 body measurements with density and lean body weight. Thigh anterior, juxta-nipple skin folds and forearm and ankle circumference were selected in the regression equation predicting body density. Multiple correlation coefficient (R) equal to 0.765 was obtained for this equation. For the predicted lean body weight, R equalled 0.930. The regression equations included body weight, thigh, anterior and juxta-nipple skin fold thicknesses, and forearm circumference. Contribution of other body measurements in the regression of these parameters was not significant. The analysis also revealed that a new set of coefficients is required for the measurements included in the published regression equations.

Fat distribution in lean and obese young Indian women: a densitometric and anthropometric evaluation

The pattern of fat distribution in lean and obese young Indian women was studied using seven girths and ten skinfold thicknesses. Though the lean and obese subjects differed significantly with respect to their body weight and total body fat content, body girths indicted that the proportion of fat distributed between the extremities and over the trunk region was essentially similar. By comparing skinfold thicknesses, it was observed that the fat women were merely an exaggeration of the fat profile pattern of the lean women. Although the pattern of subcutaneous fat distribution was similar in lean and obese subjects, the rate of fat deposition differed on different parts of the body with increase in total adiposity.

Body composition of high altitude natives on descent to the plains: a densitometric, hydrometric, and anthropometric evaluation

Body density was experimentally determined at a field location at 3,920 m on 32 medically fit and active high altitude native males using a water displacement technique. Stature, body weight and the bony widths at the elbow, wrist, knee, and ankles; and thickness of skin folds at eight sites were measured. Based on body density and bony widths, body fat, total body water (TBW), mineral mass and total cell solids (TCS) were calculated. Similar measurements were made on another group of 16 high altitude natives after one months stay in Dehli (200 m). TBW of 11 of these subjects was experimentally determined by the oral administration of 200 muCi of tritiated water. This group of subjects was physically less active in Delhi. At high altitude the natives consumed a balanced diet which provided 20.21 MJ, but in the plains the diet provided only 15.69 MJ though it was nutritionally balanced. In spite of the reduced calorie intake this group showed greater fat content in Delhi than the group located at high altitude. These men were also hyperhydrated. Hyperhydration of the lean body could be an adaptive response of the high altitude natives to the new environment. Due to the disturbed state of hydration of the lean body of these men in the plains, use of Siri's formula for the computation of total body fat is questioned.

Variations in skinfold thickness during de-acclimatisation and re-acclimatisation to high altitude. Relation to body fat content

Skinfold thickness, body weight, body water, anthropometric measurements and segment volumes were determined in 28 young and healthy Indian soldiers on return to Delhi (200 m) after staying for more than 24 months at high altitude (3500 m). The measurements were made on the 2nd day and after 3 weeks. Ten subjects were then randomly selected from this group and returned by air to the high-altitude station, and the measurements were repeated on the 3rd and 12th day of their reinduction. Though body weight and total body water increased marginally on transfer to the lower altitude, body density remained more or less unchanged. There were significant increases in the thickness of skinfolds, even when body density had increased. During this period hand and foot volumes decreased significantly. Despite significant increases in thoracic skinfold thickness, the torso volume decreased slightly. On returning to high altitude, the soldiers lost body weight, were hypohydrated and showed reduced skinfold thickness. Fat losses calculated on the basis of reduction in skinfold thickness were far in excess of those calculated from losses in body weight and in total body water. As the reduced skinfold thickness was unrelated to changes in body water content at high altitude, it seems that such reductions are due to redistribution of blood in the skin. From the results of these investigations it is concluded that variations in skinfold thickness during acclimatisation to high altitude do not accurately represent the changes in body fat content.

Surgical mentorship in low-resource environments: Opportunities and challenges, a perspective

Background and aims

In low- and middle-income countries (LMICs), a shortage of skilled surgical practitioners hampers healthcare delivery, impacting well-being and economic growth. Surgical mentorship programs offer a promising solution but face challenges in implementation. This review aims to comprehensively assess the impact of surgical mentorship programs in LMICs and identify challenges and opportunities for their development and implementation.

Methods

A thorough literature search was conducted from 2000 to 2023 using multiple databases, focusing on surgical mentorship programs in LMICs. Inclusion criteria encompassed full-text articles in English that demonstrated characteristics of mentorship. Rigorous exclusion criteria were applied to ensure high-quality evidence inclusion.

Results

Surgical mentorship programs in LMICs strengthen local surgical capacity, improve surgical skills and patient outcomes, optimize resources and technology utilization, and positively impact medical students aspiring to be surgeons. However, challenges such as resistance to change, resource limitations, financial constraints, logistical and technological challenges, and time constraints hinder their implementation.

Conclusion

Despite challenges, surgical mentorship programs hold promise for enhancing surgical capacity and healthcare quality in LMICs. Standardized metrics for accountability, innovative funding mechanisms, collaborative partnerships for scalability, interdisciplinary integration, and leveraging virtual mentorship programs are key strategies to overcome challenges and foster sustainable learning cultures, ultimately contributing to improved healthcare equity and quality in low-resource settings.

Prediction of body volume by a stepwise linear regression technique

Body volume and 35 anthropometric measurements were obtained from 88 active soldiers using standard techniques. These anthropometric measurements were examined for their possible relationships to body volume using stepwise linear regression analysis. Four measurements (Body weight, anterior thigh skinfold thickness, subscapular skinfold thickness and suprailiac skinfold thickness) accounted for 99.7% of the variation in body volume and the introduction of each of these measurements in the equation was significant. The regression equation for predicting body volume from these 4 anthropometric measurements had a multiple correlation coefficient of 0.9987 (P less than 0.001). Body weight alone was correlated with body volume to the extent of 0.9966. An attempt has therefore been made to develop a multiple linear regression equation without incorporation of body weight in the regression analysis. Nine measurements were selected by stepwise linear regression analysis for predicting body volume. These nine measurements accounted for 97.1% of the variation in body volume. These equations have been validated on another small sample of 22 soldiers. The analysis has also revealed that a direct regression of body density from the anthropometric variables gives more accurate results than when estimated body volumes are utilized for calculating body density.

Resident Physician “Moonlighting” for On-call in Transfusion Medicine: Educational Impact and Preparedness for Practice

Introduction/Objective

Resident physician moonlighting is controversial and uncommon in Pathology, usually limited to anatomic pathology grossing support. Due to an acute staffing shortage in our department, we offered senior AP/ CP residents in our program a “moonlighting” opportunity involving partnership with attendings to supervise junior residents for transfusion medicine on-call (TMO) . Given the conflicting claims of educational benefit and detriment of moonlighting, we sought to evaluate impact of TMO moonlighting activities on residents' educational experience and preparedness for clinical practice.

Methods/Case Report

Residents selected for moonlighting TMO were PGY-3/4, “exceeded expectations” on their transfusion medicine rotation and had taken resident TMO. After initial “boot camp” exercises involving common TMO scenarios, they were added to the attending on-call schedule with a fair financial incentive. They were the first resource and provided in-person support for the TMO resident. Attendings were available for consultation via a secure communications platform (phone and text). After one year, residents were surveyed regarding overall experience, sense of graduated responsibility, impact of financial incentive, preparedness for future practice, and impact on day- time service commitment. "Resident In-Service Examination" (RISE) score was used to estimate impact of TMO on medical knowledge.

Results (if a Case Study enter NA)

NA.

Conclusion

Four out of the five residents took the survey. All 4 responded “definite” for positive experience, feeling of graduated responsibility and preparedness for practice. Financial incentive was assessed favorably. No resident reported an adverse impact on their daytime service responsibility. The group median score on RISE transfusion medicine 2022 was 75th percentile with median increase in 10 percentile points. As pathology moves towards sub- specialty practice, working fluency in some areas such as TMO remains a necessity for smaller group practices. Our experience (albeit with a small group of residents) suggests that TMO moonlighting activities may better prepare the residents for this unmet need.

Awake craniotomies in South America: Advancements, challenges, and future prospects

BACKGROUND: Awake craniotomy has emerged as an advanced surgical technique, characterized by keeping the patient awake during brain surgery. In South America, awake craniotomies have grained traction in neurosurgical practices across various medical centres and hospitals, with notable practitioners contributing to its growth and refinement in the region. PURPOSE: This study aims to explore the integration and impact of awake craniotomies in South American neurosurgical practices. The focus is on understanding the benefits, challenges, and potential transformative effects of the procedure in the region. RESEARCH DESIGN: A comprehensive narrative review and analysis through a thorough examination of the existing literature. RESULTS: The findings indicate that awake craniotomies in South America offer substantial benefits, including cost savings thorugh reduced hospitalization time, quicker recovery and decreased morbidity. Enhanced safety, effective pain management and reduced anaesthesia also contribute to this. CONCLUSION: Whilst the adaptation of awake craniotomies in South America holds great promise in transforming neurosurgical care in the region, significant challenges hinder its widespread adoption. Inadequate infrastructure, limited access to equipment, financial instability, and shortages in trained healthcare providers represent challenges that need to be addressed.

Synchronous bilateral pheochromocytomas and extra-adrenal paragangliomas without specific gene mutations

Introduction/Objective

Diagnosis of hereditary paraganglioma-pheochromocytoma syndrome (H-PGL/PCC-S) should be suspected in individuals with pheochromocytoma or paraganglioma, especially those with multifocal lesions, positive family history, or early-onset disease. Recent studies suggest one-third to half of these patients have germline/syndromic associations. We present a challenging case wherein a 44-year-old female with high-risk factors, multiple paragangliomas, and bilateral pheochromocytomas did not have any identifiable syndromic involvement.

Methods/Case Report

Patient presented seven years ago with epigastric pain, weight loss of 50lbs, and chronic diarrhea. Endoscopic ultrasound revealed 2cm hypoechoic mass behind pancreas, diagnosed as neuroendocrine tumor on fine-needle aspiration. Subsequent SPECT-CT and MRI revealed multiple intra-abdominal lesions, including bilateral adrenal-lesions (right 2cm; left 1.6cm), 2.2cm aortocaval-lesion, and multifocal retroperitoneal lesions, consistent with paragangliomas, gradually increasing in size on follow-up imaging. She also developed intermittent palpitations, flushing, and blood pressure fluctuations. Additionally, multiple thyroid nodules were identified on subsequent ultrasound imaging, suspicious for malignancy on both cytology and Afirma studies. Exploratory laparotomy with left para-adrenal, right infra-renal, and aortocaval nodule-excisions revealed nested tumor cells with abundant granular purple cytoplasm, round central nuclei, prominent nucleoli, diagnosed as moderate to poorly differentiated extra-adrenal paragangliomas with increased metastatic risk based on PASS and GAPP-scoring systems. Additionally, right adrenalectomy revealed pheochromocytoma with 7/20 PASS-score and 4/10 GAPP-score suggesting increased metastatic risk.

Results (if a Case Study enter NA)

NA

Conclusion

Young age, strong family-history, multiple high-grade paragangliomas, pheochromocytomas, and suspicious thyroid nodules raise concerns for syndromic association. Multitude of autosomal-dominant syndromes, including paraganglioma-syndromes (PGL1-to PGL5), VHL, MEN2A, MEN2B, and NF1, have been reported. Genes identified in these syndromes include SDHA, SDHB, SDHC, SDHD, SDHAF2, MAX, TMEM127, VHL, NF1, RET, FH, and KIF1B. However, no mutations were identified, thus creating a dilemma in risk-stratification. This leaves out only two considerations: either sporadic PGL/PCC or a yet unidentified genetic-mutation.

Current trends and challenges: The landscape of perioperative mortality in intracranial surgeries in low- and middle-income settings: A narrative review

Background and Aims

Intracranial surgeries are pivotal in treating cerebral pathologies, particularly in resource-limited contexts, utilizing techniques such as craniotomy, transsphenoidal approaches, and endoscopy. However, challenges in low and middle income countries (LMICs), including resource scarcity, diagnostic delays, and a lack of skilled neurosurgeons, lead to elevated perioperative mortality (POM). This review seeks to identify major contributors to these challenges and recommend solutions for improved patient outcomes in neurosurgical care within LMICs.

Methods

This review examines POM in LMICs using a detailed literature search, focusing on studies from these regions. Databases like PubMed, EMBASE, and Google Scholar were utilized using specific terms related to "intracranial surgery," "perioperative mortality," "traumatic brain injuries," and "LMICs." Inclusion criteria covered various study designs and both pediatric and adult populations while excluding stand-alone abstracts and case reports.

Results

POM rates for intracranial surgeries differ widely across many low and middle-income regions: Africa sees rates from 2.5% to 39.1%, Asia between 3.6% and 34.8%, and Latin America and the Caribbean have figures ranging from 1.3% to 12%. The POM rates in LMICs were relatively higher compared to most first-world countries. The high POM rates in LMICs can be attributed to considerable delays and compromises in neurosurgical care delivery, exacerbated by late diagnoses and presentations of neurosurgical pathologies. This, coupled with limited resources, underdeveloped infrastructure, and training gaps, complicates intracranial disease management, leading to elevated POM.

Conclusion

Intracranial POM is a pronounced disparity within the neurosurgical field in LMICs. To mitigate intracranial POM, it is imperative to bolster healthcare infrastructure, amplify personnel training, foster global partnerships, and harness technologies like telemedicine. Tackling socioeconomic obstacles and prioritizing early detection through sustained funding and policy shifts can substantially enhance patient outcomes.

Exploring Health Care Disparities in Genetic Testing and Research for Hereditary Cardiomyopathy: Current State and Future Perspectives

Background  Hereditary cardiomyopathies are commonly occurring myocardial conditions affecting heart structure and function with a genetic or familial association, but the etiology is often unknown. Cardiomyopathies are linked to significant mortality, requiring robust risk stratification with genetic testing and early diagnosis. Hypothesis  We hypothesized that health care disparities exist in genetic testing for hereditary cardiomyopathies within clinical practice and research studies. Methods  In a narrative fashion, we conducted a literature search with online databases such as PubMed/MEDLINE, Google Scholar, EMBASE, and Science Direct on papers related to hereditary cardiomyopathies. A comprehensive analysis of findings from articles in English on disparities in diagnostics and treatment was grouped into four categories. Results  Racial and ethnic disparities in research study enrollment and health care delivery favor White populations and higher socioeconomic status, resulting in differences in the development and implementation of effective genetic screening. Such disparities have shown to be detrimental, as minorities often suffer from disease progression to heart failure and sudden cardiac death. Barriers related to clinical genetic testing included insurance-related issues and health illiteracy. The underrepresentation of minority populations extends to research methodologies, as testing in ethnic minorities resulted in a significantly lower detection rate and diagnostic yield, as well as a higher likelihood of misclassification of variants. Conclusions  Prioritizing minority-based participatory research programs and screening protocols can address systemic disparities. Diversifying research studies can improve risk stratification strategies and impact clinical practice.

Urinary Bladder Squamous Cell Carcinoma In-Situ in a Background of Condyloma Acuminatum – A Diagnostic Challenge

Introduction/Objective

Condyloma acuminatum is a rare lesion of the urinary bladder and urethra, usually associated with extensive anogenital condyloma acuminatum and immunosuppression. It is considered a risk factor for developing urinary bladder squamous cell carcinoma.

Methods/Case Report

We report a case of an 80-year-old male with a history of invasive squamous cell carcinoma of the anus, status-post chemoradiation ten years prior, and renal transplantation for end-stage renal disease 15 years prior. He presented with a lesion adjacent to the neoureteral orifice at the bladder dome. Biopsy revealed nonkeratinizing, hyperplastic papillary fronds of squamous epithelium with koilocytic change and viral atypia. The tumor was positive for p16, GATA3, and p40 and negative for high-risk and low-risk Human Papilloma Virus by in-situ hybridization. However, the morphology was consistent with squamous cell carcinoma in-situ arising in a background of condyloma acuminatum, which was concurred by an outside expert. Bladder condyloma acuminata are often challenging to recognize, given their extreme rarity and the possibility of negative low-risk and high-risk Human Papilloma Virus tests. Lack of prior history of anogenital condylomas can further obscure this diagnosis.

Results (if a Case Study enter NA)

NA.

Conclusion

This case raises awareness of condyloma acuminatum as a rare entity that needs to be considered in the differential diagnosis of bladder tumors, especially in immunosuppressed patients. Given that the treatment strategies for squamous cell carcinoma arising from condyloma acuminatum differ from that for urothelial carcinoma with squamous differentiation, distinguishing these lesions from one another is imperative.

Challenging diagnosis of sarcomatoid hepatic mesothelioma: a case report with review of literature

Introduction

Mesothelioma is a rare and aggressive cancer that is primarily caused by asbestos exposure. However, cases of mesothelioma without asbestos exposure suggest the involvement of other risk factors. Sarcomatoid mesothelioma, which is characterized by spindle-shaped cells, is a particularly aggressive subtype with limited treatment options.

Case presentation

The authors present a case of a 72-year-old man with no history of asbestos exposure who presented with abdominal pain, fatigue, and weight loss. Imaging revealed a large cystic mass in the liver. A Liver biopsy confirmed the diagnosis of sarcomatoid mesothelioma. Immunohistochemistry results further supported this diagnosis. Due to the advanced stage and tumor size, surgical resection was not feasible. Palliative chemotherapy was initiated, but the patient's condition deteriorated rapidly, leading to his demise.

Conclusion

This case highlights the complexity of mesothelioma and the need for further research to identify the nonasbestos-related risk factors. Understanding alternative causative agents and mechanisms is crucial for the early detection, the development of targeted therapies, and improving patient outcomes. The presented case contributes to the existing literature and aligns with the Surgical CAse REport (SCARE) Criteria.

Solid Cell Nests Hyperplasia (Ultimobranchial Body Remnants) of the Thyroid: A Pitfall

Introduction/Objective

Solid cell nests (SCN) are small epithelial cell nests interspersed within thyroid parenchyma, resembling squamous/transitional epithelium. SCNs, which are ultimobranchial remnants, are popularly considered pluripotent stem-cells responsible for developing follicular and C-cells. While SCNs are not an uncommon incidental findings in thyroid, solid cell nest hyperplasia is rare. SCNs are often mistaken for benign entities such as C-cell hyperplasia (CCH) or malignant lesions such as papillary thyroid carcinoma (PTC), metastatic squamous cell carcinoma, or medullary thyroid microcarcinoma (MTC).

Methods/Case Report

To reiterate this diagnostic dilemma, we present a case of a 57-year-old male with a six-year history of Hashimoto thyroiditis and multiple bilateral thyroid nodules. Ultrasonography revealed two nodules, one in each lobe, measuring 2.0x1.9x1.8cm(right) and 1.6x1.5x1.5cm(left). Both were solid, hypoechoic nodules with smooth margins and no echogenic foci. Fine-needle aspiration of right nodule was suspicious for follicular neoplasm, Hürthle- cell type, and the left nodule was atypia of unknown significance. Right-hemithyroidectomy specimen revealed follicular adenoma and oncocytic adenomatous nodules in a background of florid lymphocytic thyroiditis (Hashimoto). In two blocks, small solid nests of cells were identified, largest focus measuring 0.5 cm. The cells were polygonal to epithelioid with moderate amphophilic cytoplasm. Nuclei were centrally located, irregular to oval with occasional grooves. While nests had a squamoid appearance, they did not have intercellular bridges. Although nuclear grooves and evenly dispersed chromatin and chromocenters were noted, they lacked optical clearing or intra-nuclear inclusions characteristic for PTC. Thus, excluding these two possibilities, primary diagnostic considerations were SCN versus CCH. Immunohistochemical analysis showed cells positive for P63 and CK5/6 and negative for PAX-8, TTF-1, thyroglobulin, CEA, and calcitonin.

Results (if a Case Study enter NA)

NA

Conclusion

If wrongly diagnosed as CCH, patients may be placed in a high-risk category for possible development of MTC. It is, thus, necessary to be aware of SCN, which can occasionally become hyperplastic, to prevent misdiagnosis.

EBV+ Inflammatory Pseudotumor-like Follicular/Fibroblastic Dendritic Cell Sarcoma: An Uncommon and Challenging Tumor

Casestudy: Inflammatory pseudotumor-like follicular/fibroblastic dendritic cell sarcoma (IP-L FDC/FRC) is a rare dendritic cell neoplasm recognized as a specific entity in the WHO classification of tumors of the hematopoietic and lymphoid tissues. The tumor has specific clinical features, including a predominance in young to middle-aged women typically involving the liver or spleen, with neoplastic cells typically positive for Epstein-Barr virus.

Morphologically, the tumor poses a diagnostic challenge to distinguish it from inflammatory pseudotumor and inflammatory myofibroblastic tumor, with which it shares considerable morphologic and immunohistochemical overlap. We present a case report of a 35-year-old female who presented with weight loss, malaise, and intraabdominal mass. MRI revealed a 14 cm large ovoid solid mass with central hemorrhage and necrosis. Biopsy and subsequent resection of the tumor confirmed IP-L FDC/FRC sarcoma. Histologically, the tumor was composed of spindle cells admixed with many lymphocytes and prominent plasma cells. Immunohistochemical stains showed neoplastic spindle cells focally positive for dendritic cell markers CD21, CD23, and CD35, diffuse positivity for SMA, and striking in situ hybridization for Epstein-Barr virus (EBER). Due to its rarity, biologic behavior and outcomes are not well established. The tumors are generally regarded as indolent with a risk of repeated intraabdominal recurrence, although recurrences may be related to the ease and completeness of surgical resection. It is essential to distinguish this tumor from other high- grade sarcomas with greater metastatic potential and overall worse prognosis.

Relationship of body density and lean body mass to body measurements: application to Indian soldiers of relationships developed for people of European descent

Body density was measured directly in 90 young Indian soldiers from the Gurkha, Rajput and South Indian regiments. Body density was also predicted on the same subjects using skinfold thicknesses as well as other anthropometric measurements. Validity of the regression equations of Pascale, Grossman, Sloan and Frankel (1956), Sloan (1967) and Wilmore and Behnke (1969) was also tested on these Indian soldiers. Lean body mass was estimated directly from another equation of Wilmore and Behnke (1969), where skinfold thicknesses were not involved. The results indicate that all the body density predicting equations underestimate the measured body density, with the equation of Sloan (1967) approximately more closely to the actual value in these ethnic groups. The equation of Wilmore and Behnke (1969) regresses lean body weight from body measurement satisfactorily in all the ethnic groups of this study.

Efficacy and Safety of Tenofovir Plus Entecavir Combination Therapy Versus Tenofovir Monotherapy in Chronic Hepatitis B Virus Patients With Resistance or Partial Response to Entecavir: A Systematic Review and Meta-analysis

Background and objectives

Chronic hepatitis B virus remains a significant cause of liver disease in the developing world, leading to sequelae such as hepatocellular carcinoma. While entecavir (ETV) serves as a first-line treatment, its growing resistance rates underscore the need to explore viable alternatives. Tenofovir disoproxil fumarate (TDF) monotherapy and entecavir plus tenofovir (TDF + ETV) combination therapy are both employed as treatments, but one's efficacy over another is in question. This meta-analysis aims to investigate any primacy of either treatment.

Methods

We conducted a comprehensive literature search across PubMed/Medline, Embase, Cochrane Central, Web of Science, and China National Knowledge Infrastructure from inception till 7th October 2024. Studies comparing the safety and efficacy of TDF monotherapy versus TDF + ETV combination therapy in patients resistant to entecavir were considered. Data about the virologic response (VR), virologic breakthrough, HbeAg seroconversion, HbeAg/HbsAg seroclearance, and alanine aminotransferase normalization were extracted. Relative risks (RRs) and their corresponding 95% confidence intervals (CIs) were calculated, pooled, and analyzed in a random-effects model. P-value <0.05 was regarded as significant for all analyses.

Results

Nine studies, comprising 335 patients undergoing monotherapy and 352 patients undergoing combination therapy, satisfied the criteria. TDF + ETV combination therapy was found slightly advantageous to TDF monotherapy, stimulating a VR at 48 weeks (RR 1.081 95% CI: [1.001-1.167] P = 0.046, I2 = 0%), along with the HbeAg seroconversion rate (RR 1.711 95% CI: [1.005-2.913] P = 0.048, I2 = 0%). There were no significant adverse events in individual studies to warrant a meta-analysis.

Conclusions

TDF + ETV shows slightly better efficacy to TDF monotherapy over a 48-week treatment regimen, with minimal safety concerns. However, further high-quality studies like randomized controlled trials are needed to further solidify conclusions, with this meta-analysis only achieving borderline significances.

Registration

This review is registered on the PROSPERO database (ID: CRD42024581443).