Microsecond Isomer at the N=20 Island of Shape Inversion Observed at FRIB.

Excited-state spectroscopy from the first experiment at the Facility for Rare Isotope Beams (FRIB) is reported. A 24(2)-µs isomer was observed with the FRIB Decay Station initiator (FDSi) through a cascade of 224- and 401-keV γ rays in coincidence with ^{32}Na nuclei. This is the only known microsecond isomer (1 µs≤T_{1/2}<1 ms) in the region. This nucleus is at the heart of the N=20 island of shape inversion and is at the crossroads of the spherical shell-model, deformed shell-model, and ab initio theories. It can be represented as the coupling of a proton hole and neutron particle to ^{32}Mg, ^{32}Mg+π^{-1}+ν^{+1}. This odd-odd coupling and isomer formation provides a sensitive measure of the underlying shape degrees of freedom of ^{32}Mg, where the onset of spherical-to-deformed shape inversion begins with a low-lying deformed 2^{+} state at 885 keV and a low-lying shape-coexisting 0_{2}^{+} state at 1058 keV. We suggest two possible explanations for the 625-keV isomer in ^{32}Na: a 6^{-} spherical shape isomer that decays by E2 or a 0^{+} deformed spin isomer that decays by M2. The present results and calculations are most consistent with the latter, indicating that the low-lying states are dominated by deformation.

Crossing N=28 Toward the Neutron Drip Line: First Measurement of Half-Lives at FRIB.

New half-lives for exotic isotopes approaching the neutron drip-line in the vicinity of N∼28 for Z=12-15 were measured at the Facility for Rare Isotope Beams (FRIB) with the FRIB decay station initiator. The first experimental results are compared to the latest quasiparticle random phase approximation and shell-model calculations. Overall, the measured half-lives are consistent with the available theoretical descriptions and suggest a well-developed region of deformation below ^{48}Ca in the N=28 isotones. The erosion of the Z=14 subshell closure in Si is experimentally confirmed at N=28, and a reduction in the ^{38}Mg half-life is observed as compared with its isotopic neighbors, which does not seem to be predicted well based on the decay energy and deformation trends. This highlights the need for both additional data in this very exotic region, and for more advanced theoretical efforts.

Addition of oral fexofenadine to topical therapy leads to a significantly greater reduction in the serum interleukin-31 levels in mild to moderate paediatric atopic dermatitis.

BACKGROUND: Recent evidence has suggested that oral antihistamines could have a beneficial role in atopic dermatitis (AD) because of their anti-inflammatory action. AIM: To evaluate the effectiveness of adding an oral second-generation, nonsedating, H1-receptor antihistamine (fexofenadine) to topical treatment in AD. METHODS: In this prospective randomized study, 50 patients with a diagnosis of mild to moderate AD were recruited and randomized into two groups: Group A was given appropriate topical treatment (topical tacrolimus 0.03-0.1% ointment once daily along with topical fluticasone propionate 0.05% cream once daily, as well as paraffin-based emollients) combined with oral fexofenadine, while Group B was given appropriate topical treatment only. Both groups received the respective treatments for 8 weeks. RESULTS: There was no significant difference between the two groups in terms of the SCORing Atopic Dermatitis and the 5-dimensions Itch Scale at any of the time points (Weeks 2, 4 and 8). However, in the fexofenadine group, the level of serum interleukin (IL)-31 decreased significantly from baseline to Week 8 of treatment. CONCLUSIONS: Although we could not conclusively confirm the clinical efficacy of adding oral fexofenadine to topical treatment in AD, serological evaluation indicates that fexofenadine treatment can lead to significant lowering of serum IL-31 levels in patients with AD.

Assessment toolbox for Indian medical graduate competencies.

The new competency-based medical education curriculum for Bachelor of Medicine and Bachelor of Surgery is being implemented in a phased manner in medical colleges across India since the year 2019. The Graduate Medical Education Regulations enlist a total of 35 global competencies for the five roles expected of an Indian medical graduate, the roles being clinician, communicator, leader, professional, and life-long learner. Along with an effective implementation of the new curriculum, both in spirit and in action, it is imperative to assess the listed competencies. The new curriculum demands a more careful and mature selection of assessment tools, based on the competency and its expected level of achievement. It is these two variables that make choosing the right assessment method not just a matter of choice, but also of expertise. An array of tools in our armamentarium can sometimes separate confuse and the teachers. So, using the right tool, in the right context, at the right juncture, supplemented by other tools, and backed by constructive feedback, can help nurture the good intent ingrained in the competency-based curriculum. Hence, an attempt was made to compile an assessment toolbox for various global competencies. A PubMed, Science Direct and Google Scholar search, with relevant keywords was carried out. To the initially extracted 90,121 articles, limitations were applied, duplicates were removed and screening for assessment of global competencies and its attributes was done to select 232 articles. Finally, 31 articles were used for designing the proposed toolbox. Prioritization for the tools for the global competencies was based on thorough literature review and extensive discussion. The evolved assessment toolbox is presented in this article, which would help teachers pick the most useful methods of assessment for global competencies.

Ultrasound-guided sacral multifidus plane block for analgesia following excision of sacrococcygeal teratoma in two neonates.

Peri-operative pain management in the neonate with a sacrococcygeal teratoma poses significant challenges to the anaesthetist. Involvement of the sacrococcygeal area by the tumour often prevents the use of conventional regional anaesthetic techniques such as caudal or epidural analgesia, with a subsequent reliance on intravenous opioids and paracetamol. Since opioids are associated with respiratory depression, constipation and urinary retention, there is high incidence of opiophobia with consequent inappropriate dosage prescription, particularly in the paediatric population. We describe the use of an ultrasound-guided sacral multifidus plane block in two neonates undergoing surgical excision of sacrococcygeal teratoma. The block is technically easy to perform and also avoids traversing critical structures. Hence, it may be regarded as a promising analgesic technique for painful interventions in the sacrococcygeal area.

Blended programmatic assessment for competency based curricula.

The uncertainty in all spheres of higher education due to the COVID-19 pandemic has had an unprecedented impact on teaching-learning and assessments in medical colleges across the globe. The conventional ways of assessment are now neither possible nor practical for certifying medical graduates. This has necessitated thoughtful considerations in making adjustments to the assessment system, with most institutions transitioning to online assessments that so far have remained underutilized. Programmatic assessment encourages the deliberate and longitudinal use of diverse assessment methods to maximize learning and assessment and at present can be utilized optimally as it ensures the collection of multiple low-stake assessment data which can be aggregated for high-stake pass/fail decisions by making use of every opportunity for formative feedback to improve performance. Though efforts have been made to introduce programmatic assessment in the competency-based undergraduate curriculum, transitioning to online assessment can be a potential opportunity if the basic tenets of programmatic assessment, choice of online assessment tools, strategies, good practices of online assessments and challenges are understood and explored explicitly for designing and implementing online assessments. This paper explores the possibility of introducing online assessment with face-to-face assessment and structuring a blended programmatic assessment in competency-based medical education.

Severe epidermolysis bullosa/Kindler syndrome-like phenotype of an autoinflammatory syndrome in a child.

A 5-year-old boy presented with generalized cutaneous erosions, severe scarring, depigmentation and contractures affecting major joints. The lesions had initially affected his ears, nose, feet, and the genital and ocular mucosa, leading to significant depigmentation, scarring, contractures and mutilation. The whole of the trunk and limbs were involved at the time of presentation, with the exception of some islands of spared skin on the proximal thighs, legs, nipples and external genitalia. Electron microscopy revealed a split in the sublamina densa with the absence of anchoring fibrils, suggestive of dystrophic epidermolysis bullosa (EB). Immunofluorescence antigen mapping demonstrated a broad reticulate pattern of staining with collagen IV, VII, and laminin 332 in the floor of the blister, suggestive of Kindler syndrome. Next-generation sequencing revealed a de novo heterozygous missense mutation (a variant of unknown significance) in exon 22 of the phospholipase-C gamma 2 gene (PLCG2), which resulted in a substitution of serine by asparagine at codon 798 (p.Asp798Ser), a result that was validated using Sanger sequencing. The child was diagnosed with PLCG2-associated antibody deficiency and immune dysregulation (PLAID)/autoinflammation and PLCG2-associated antibody deficiency and immune dysregulation (APLAID) syndrome. The cutaneous and corneal erosions, inflammation and scarring of this magnitude, and the eventual result of death have not been described previously for the PLAID/APLAID spectrum previously. In conclusion, this was an unusual acquired autoinflammatory severe EB-like disease that may be associated with de novo PLCG2 mutation.

The power of subjectivity in competency-based assessment.

With the introduction of competency-based undergraduate curriculum in India, a paradigm shift in the assessment methods and tools will be the need of the hour. Competencies are complex combinations of various attributes, many of which being not assessable by objective methods. Assessment of affective and communication domains has always been neglected for want of objective methods. Areas like professionalism, ethics, altruism, and communication-so vital for being an Indian Medical Graduate, can be assessed longitudinally applying subjective means only. Though subjectivity has often been questioned as being biased, it has been proven time and again that a subjective assessment in expert hands gives comparable results as that of any objective assessment. By insisting on objectivity, we may compromise the validity of the assessment and deprive the students of enriched subjective feedback and judgement also. This review highlights the importance of subjective assessment in competency-based assessment and ways and means of improving the rigor of subjective assessment, with particular emphasis on the development and use of rubrics.

Paediatric morphoea: a holistic review. Part 2: diagnosis, measures of disease activity, management and natural history.

Paediatric morphoea is a debilitating fibrosing disorder of uncertain aetiology, affecting the skin and subcutaneous tissues. Defining optimum management strategies in paediatric morphoea remains an ongoing challenge, owing to the varied presentations and a relative paucity of paediatric-specific studies. We performed a literature search on PubMed, MEDLINE and Google Scholar, using keywords such as 'pediatric morphea', 'juvenile localised scleroderma' and 'juvenile systemic sclerosis'. Relevant studies, including randomized trials, reviews of standard current guidelines and original research articles, were selected and results analysed before summarizing them. In Part 1 of this review, we described the epidemiology, aetiopathogenesis and clinical classification; in this part, we discuss the diagnosis, markers of disease activity, management and natural history in paediatric morphoea.

Paediatric morphoea: a holistic review. Part 1: epidemiology, aetiopathogenesis and clinical classification.

Morphoea, also known as localized scleroderma, is a debilitating fibrosing disorder of uncertain aetiology, affecting the skin and subcutaneous tissues. Paediatric-onset disease is not uncommon and is associated with frequent relapses. The disease has complex pathogenetic mechanisms and multiple clinical subtypes, and affects children of all ages. Recent research has focused on elucidating the disease pathophysiology and identifying measures of disease activity. We performed a literature search on PubMed, MEDLINE and Google Scholar, using keywords such as 'pediatric morphea', 'juvenile localised scleroderma' and 'juvenile systemic sclerosis'. Relevant studies, including randomized trials, reviews of standard current guidelines and original research articles, were selected, and results were analysed before being summarized. In the first of this two-part review, we provide a bird's-eye view of the current literature concerning the epidemiology, aetiopathogenesis and clinical classification of paediatric morphoea; in Part 2, we review the diagnosis, markers of disease activity, management and natural history.

Azathioprine induced pancreatitis, polyarthritis and panniculitis (PPP) syndrome in a patient with Crohn's disease.

Azathioprine and 6-mercaptopurine have been widely used for maintenance of remission in patients with inflammatory bowel disease. The use of thiopurines is associated with multiple adverse effects including dose dependent cytopenias or idiosyncratic reaction. We report about a case of azathioprine related pancreatitis associated with polyarthralgia and panniculitis. Pancreatitis, polyarthritis and panniculitis (PPP) syndrome is an uncommon phenomenon which may accompany a number of pancreatic diseases including acute or chronic pancreatitis or pancreatic malignancy. To the best of our knowledge, this is the first report of Azathioprine related PPP syndrome.

Uranium distribution in groundwater and assessment of age dependent radiation dose in Amritsar, Gurdaspur and Pathankot districts of Punjab, India.

A comprehensive study of seasonal variation of uranium distribution in groundwater of Amritsar, Gurdaspur and Pathankot districts of Punjab, India and assessment of associated radiological risks, chemical risks and effective radiation dose for different age groups, was conducted to determine its health impact on humans residing in these regions. Physicochemical parameters such as pH, EC, TDS, total hardness and contents of various anions such as carbonates/bicarbonates, chlorides, fluorides, nitrates, sulphates and phosphates in groundwater were also analysed to determine correlation between groundwater chemistry and uranium distribution. The average values of uranium concentration in ground water samples of Amritsar, Gurdaspur and Pathankot districts were found to be 8.6 µg L-1, 4.3 µg L-1 and 3.0 µg L-1, respectively, in pre-monsoon and 8.8 µg L-1, 4.9 µg L-1 and 3.4 µg L-1, respectively, in post-monsoon. The uranium concentration in majority of the ground water samples was found to be below the permissible limit of 30 µg L-1 recommended by World Health Organization (WHO, 2011). In all three districts, TDS, EC and bicarbonates were found to have positive correlation with observed uranium contents in both seasons. The annual effective dose due to ingestion of uranium through drinking water was found to be less than the prescribed limit of 100 µSv y-1 given by WHO (2004). Radiological and chemical toxicity risk assessment of uranium in groundwater was also carried out and found to be within the permissible values of 1.67 × 10-4 and 4.53 µg kg-1 day-1 respectively, recommended by Atomic Energy Regulatory Board (AERB, 2004).

Investigation of high-frequency hearing loss and outer hair cell function of the cochlea in patients with psoriasis: a case-control study.

The inner ear can be the target of autoimmune attacks, and sensorineural hearing loss can occur as a complication in various non-organ-specific autoimmune diseases. The aim of this study was to compare cochlear functions and hearing evaluation in patients with psoriasis and controls. In total, 29 patients with psoriasis and 30 healthy controls (HCs) were included in the study. Pure-tone audiometry at 250, 500, 1000, 2000, 4000, 8000, 10 000, 12 000, 14 000 and 16 000 Hz was performed for patients as HCs, as were immittance measures including tympanometry, acoustic reflex and otoacoustic emission testing. There were statistically significant (P < 0.05) differences between patients and HCs for pure-tone thresholds at high frequencies, and for distortion product otoacoustic emission (DPOAE) responses and signal : noise ratio at all frequencies. In our study, based on DPOAE and audiological findings, there was damage to the outer hair cells of the cochlea, resulting in high-frequency hearing loss in patients with psoriasis.