Shear wave elastography of tibial nerve in patients with diabetic peripheral neuropathy-A cross-sectional study.

OBJECTIVE: To explore the role of shear wave elastography of the tibial nerve as a potential ultrasonographic method for the diagnosis of tibial neuropathy in patients with type 2 diabetes. MATERIALS AND METHODS: This cross-sectional study included 50 subjects each in case (patients with diabetic tibial neuropathy diagnosed on the basis of clinical features and nerve conduction study) and control groups (non-diabetic non-neuropathic healthy volunteers). The exclusion criteria included the presence of type 1 diabetes, a known history of neuropathy from other causes except for type 2 diabetes, or a history of leg or ankle fracture. Cross-sectional area and shear wave velocity values of the tibial nerve were measured in both groups. Demographic details and body mass index were obtained in both groups and additionally, the duration of type 2 diabetes and HbA1c values in the case group were also noted. Wilcoxon Mann-Whitney U test was used to compare these variables in study groups. ROC curve analysis provided additional findings. RESULTS: Tibial nerve stiffness was significantly higher in the case group (p-value < 0.001). The study groups did not significantly differ in the Cross-sectional area of the tibial nerve (p-value 0.57). The case group exhibited a higher frequency of loss of the fascicular pattern of the tibial nerve (40% vs 18%, p-value 0.027). Duration of diabetes mellitus and HbA1c values did not significantly affect Shear wave velocity values in the case group. At the cut-off value of Shear wave velocity of 3.13 m/s, sensitivity and specificity to diagnose diabetic peripheral neuropathy were 94% and 88% respectively. CONCLUSION: Increased nerve stiffness is seen in patients with diabetic peripheral neuropathy. Shear wave elastography might prove as a novel noninvasive technology for screening/early diagnosis of diabetic peripheral neuropathy.

Role of diffusion kurtosis imaging in evaluating microstructural changes in spinal cord of patients with cervical spondylosis.

STUDY DESIGN: Analytical cross-sectional study. PURPOSE: To study the role of diffusion kurtosis imaging (DKI) in evaluating microstructural changes in patients with cervical spondylosis. OVERVIEW OF LITERATURE: Cervical spondylosis is a common progressive degenerative disorder of the spine. Conventional magnetic resonance imaging (MRI) can only detect the changes in the spinal cord once there are visual signal changes; hence, it underestimates the extent of the injury. Newer imaging techniques like Diffusion Tensor and Kurtosis Imaging can evaluate the microstructural changes in cervical spinal cord before the obvious signal changes appear. METHODS: Conventional MRI, diffusion tensor imaging (DTI), and DKI scans were performed for 90 cervical spondylosis patients on 1.5-T MR Siemens Magnetom aera after obtaining informed consent. Eight patients were excluded due to poor image quality. Fractional anisotropy (FA) colour maps and diffusion kurtosis (DK) maps corresponding to spinal cord cross sections at C2-C3 intervertebral disc level (control) and at the most stenotic levels were obtained. Modified Japanese Orthopaedic Association (mJOA) scoring was used for clinical assessment of the spinal cord function. The changes in DTI and DKI parameters and their correlation with mJOA scores were analysed by SPSS 23 software. RESULTS: In our study, mean FA and mean kurtosis (MK) values at the stenotic level (0.54, 1.02) were significantly lower than values at the non-stenotic segment (0.70, 1.27). The mean diffusivity (MD) value at the stenotic segment (1.25) was significantly higher than in the non-stenotic segment (1.09). We also observed a strong positive correlation between mJOA score and FA and MK values and a negative correlation between mJOA score and MD values, suggesting a correlation of FA, MK, and MD with the clinical severity of the disease. CONCLUSION: Addition of DTI and DKI sequences helps in early identification of the disease without any additional cost incurred by the patient.

Ultrasonographic Evaluation of Thickness and Stiffness of Achilles Tendon and Plantar Fascia in Type 2 Diabetics Patients: A Cross-sectional Observation Study.

Background: Diabetes mellitus (DM) can contribute to the development of foot ulcers, a known complication of DM with a high financial and social burden. Achilles tendon (AT) and plantar fascia (PF) are well known to play an important role in foot biomechanics. The present study focuses on the alteration in thickness and stiffness of the AT and PF in Type 2 DM patients compared with the normal controls. Methods: A cross-sectional observational study was conducted with 55 DM patients and 55 healthy volunteers as controls. The thickness of the AT and PF were measured using B-mode ultrasound and stiffness was measured using shear wave elastography. Both the thickness and stiffness in the patient group and controls were compared. The values were also compared with the clinical and demographic profiles of the patients. Results: DM patients had considerably thicker AT and PF than controls (P < 0.05); mean values of AT thickness for DM patients and controls were 5.66 ± 0.54 mm and 4.61 ± 0.39 mm, respectively, and for PF were 2.53 ± 0.51 mm and 1.97 ± 0.19 mm, respectively. Furthermore, the stiffness of AT and PF was significantly (P < 0.05) lower in DM patients compared to controls, suggestive of softening of AT and PF in Type 2 DM patients. Mean values of shear wave velocity for DM patients and controls in AT were 5.53 ± 0.54 m/s and 7.25 ± 0.61 m/s, respectively, and for PF, 4.53 ± 0.89 m/s and 6.28 ± 0.88 m/s, respectively. Conclusion: We conclude that there is softening and thickening of the AT and PF in Type 2 DM patients, which can impair foot biomechanics.

Computed tomography virtual oesophagography for the grading of oesophageal varices in cirrhotic liver disease patients with upper gastrointestinal endoscopic examination as the gold standard: a diagnostic validation study.

Purpose: Virtual endoscopy is a postprocessing method using three-dimensional computed tomography (CT), which produces views of the inner surfaces of the human body like those produced by fibreoptic endoscopy. To evaluate and categorise patients who require medical or endoscopic band ligation to prevent oesophageal variceal bleed, a less invasive, less expensive, better tolerated, and more sensitive modality is required, as well as to reduce the use of invasive procedures in the follow-up of patients who do not require endoscopic variceal band ligation. Material and methods: A cross-sectional study was conducted in the Department of Radiodiagnosis in association with the Department of Gastroenterology. The study was conducted over a period of 18 months from July 2020 to January 2022. The sample size was calculated as 62 patients. Patients were recruited on the basis of inclusion and exclusion criteria after giving informed consent. CT virtual endoscopy was performed through a dedicated protocol. Classification of variceal grading was done independently by a radiologist and endoscopist who were blinded to each other's findings. Results: The diagnostic performance of oesophageal varices detection by CT virtual oesophagography was good, with sensitivity: 86%, specificity: 90%, PPV: 98%, NPV: 56%, and diagnostic accuracy: 87%. There was substantial agreement between the 2 methods, and this agreement was statistically significant (Cohen's k = 0.616, p ≤ 0.001). Conclusions: Based on our findings, we conclude that the current study has the potential to change the way chronic liver disease is managed, as well as generate similar medical research endeavours. A multicentric study with a large number of patients is needed to improve the experience with this modality.

Prevalence and characteristics of venous thromboembolism in severe exacerbation of chronic obstructive pulmonary disease in a tertiary care hospital in India.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) carries a high risk of venous thromboembolism (VTE). Pulmonary embolism (PE) and AECOPD increase the mortality and morbidity risk associated with each other. Racial and ethnic differences in VTE risk have been documented in multiple studies. However, there is a dearth of reliable Indian data on the same. This study was planned to find the prevalence of VTE in the setting of severe AECOPD in a tertiary care hospital in India and to identify the clinical, laboratory and radiological characteristics of VTE in severe AECOPD. A total of 156 consecutive patients admitted with severe AECOPD and meeting the specified inclusion and exclusion criteria were recruited. Thorough workup of all patients was done including ABG, serum D dimer, ECG, compression ultrasound of lower limbs and 2-D echocardiography. Patients with high pre-test probability score, or intermediate pre-test probability score at presentation with serum D dimer above the age adjusted cut-off underwent computerised tomography pulmonary angiography (CTPA).  Results were analysed using SPSS version 23.  Sixteen (10.3%) patients had VTE, 15 (93.75%) of them being cases of isolated PE. Female gender, higher cumulative past exposure to corticosteroid, higher alveolar-arterial gradient, right ventricular dysfunction, and higher mean pulmonary artery pressure were associated with increased risk for VTE. The prevalence of VTE in AECOPD in this study among an Indian population is higher than among other Asians, but lower than among the Blacks, the Caucasians and the Middle-East ethnicities. Since a vast majority of VTE presents as PE without DVT in the setting of AECOPD, the absence of deep vein thrombosis of lower limbs does not rule PE in the setting.

Assessing the Impact of the Portfolio Workshop and the Use of the Rubric Matrix for Reflective Writing on Medical Faculty and Students.

Purpose The portfolio can be used as a crucial tool for self-reflection, which allows us not only to showcase achievements but also course correct on our personal and professional journey. However, there is a significant lack of awareness among medical professionals about portfolios. Arranging a workshop to impart this knowledge could be a potential mitigation approach. This study aims to assess the impact of workshops on portfolios on students' and faculty's knowledge. In addition, the study also analyzes the effect of using rubrics on reflective writing skills. Method A portfolio workshop was organized for the medical faculty and students in the Bundelkhand Government Medical College, Sagar, M.P. The Kirkpatrick model of training evaluation along with a rubric for the evaluation of reflective writing skills were used to measure the effectiveness of the workshop. Pre and post-tests for the workshop, pre and post-reflective writing skills, and workshop feedback were collected using questionnaires. The Shapiro-Wilk test and the Wilcoxon signed rank test were applied to the data collected. Results Out of 89 registrations for the workshop, only 81 people consented to the workshop and participated in the study. The total number of faculty was only 17 and the rest were students from all the phases. Both the Shapiro-Wilk test and the Wilcoxon signed rank test showed a significantly small p-value, stating that there was a significant positive impact on the knowledge, perception, and effectiveness of the workshop. Conclusion This study clearly outlines the positive impact of conducting a workshop on portfolios. A significant increase in participants' knowledge of portfolios is identified. Similarly, employing rubrics has a significant increase in the quality of reflective writing skills.

How can quantum computing be applied in clinical trial design and optimization?

Clinical trials are necessary for assessing the safety and efficacy of treatments. However, trial timelines are severely delayed with minimal success due to a multitude of factors, including imperfect trial site selection, cohort recruitment challenges, lack of efficacy, absence of reliable biomarkers, etc. Each of these factors possesses a unique computational challenge, such as data management, trial simulations, statistical analyses, and trial optimization. Recent advancements in quantum computing offer a promising opportunity to overcome these hurdles. In this opinion we uniquely explore the application of quantum optimization and quantum machine learning (QML) to the design and execution of clinical trials. We examine the current capabilities and limitations of quantum computing and outline its potential to streamline clinical trials.

Utility of MR lymphangiography in chylous ascites: A report of two cases.

Dynamic contrast-enhanced (DCE) lymphangiography is a novel imaging technique with a potential role in suspected cases of lymphatic leaks. A 15-year-old male with a post operative chylous leak and an 8-year-old male who developed chylous ascites secondary to disseminated tuberculosis are presented. Both children underwent MR lymphangiography. Contribution: The role of DCE-MR lymphangiography in cases of chylous ascites to help guide appropriate management.

Comparison of clinico-radiological profile, optical coherence tomography parameters, and outcome in MOGAD and Neuromyelitis optica spectrum disorder subtypes: A prospective observational study.

Objectives: The objectives of the study were to compare the clinico-radiological profile, optical coherence tomography (OCT) parameters and outcome in Myelin Oligodendrocyte Glycoprotein-IgG-associated disorders (MOGAD) and Neuromyelitis Optica Spectrum disorder subtypes. Materials and Methods: This prospective study involved collection of data regarding neurological assessment, neuroimaging, cerebrospinal fluid analysis, OCT parameters, treatment and outcome. Disease severity and disability were assessed using Expanded Disability Status Scale and modified Rankin scale. Patients were categorized into aquaporin-4 (AQP4+), MOGAD, and double negative (DN; both AQP4 and MOG negative). Results: Among 31 patients included, 42% were AQP4+, 32.2% were MOGAD, and 25.7% were DN. The median age at onset was comparable (AQP4+ vs. MOGAD vs. DN = 28 years vs. 24.4 years vs. 31.5years; P = 0.31). Females predominated in AQP4+ compared to MOGAD group (76.9% vs. 30%; P = 0.02). Majority of patients (73.5%) had a relapsing course with a median of two (range = 1-9) relapses. Ninety-nine demyelinating events occurred: Transverse myelitis (TM) in 60/99 (60.6%), optic neuritis (ON) in 43/99 (43.4%), area postrema (AP) syndrome in 20/99 (20.1%), and optico-spinal syndrome in 10/99 (10.1%). ON was common in MOGAD than AQP4+ patients (58.6% vs. 32.1%; P = 0.03). Spinal cord and brain lesions on magnetic resonance imaging (MRI) were seen in 90.3% and 54.8% patients, respectively. A significantly higher proportion of AQP4+ patients showed longitudinally extensive transverse myelitis as compared to MOGAD group (69.2 % vs. 20 %; P = 0.04), specifically involving dorsal cord (92.3% vs. 50%; P = 0.02). MRI brain lesions, especially involving AP, was frequent in DN than MOGAD (47.1% vs. 6.9%; P = 0.003) and AQP4+ (47.1% vs. 18.9%; P = 0.03) patients. AQP4+ group showed significant nasal RNFL thinning on OCT (P = 0.04). Although 6-month good functional outcome was better in MOGAD than DN and AQP4+ (80% vs. 71.4% vs. 41.7%) groups, they were comparable (P = 0.13). Conclusion: Nearly three-fourth of our patients showed a relapsing course, with TM being the most common clinical presentation. AQP4+ group showed female preponderance, frequent dorsal cord longitudinally extensive transverse myelitis, less frequent ON, and greater nasal RNFL thinning compared to MOGAD group. MRI brain lesions were more common in DN patients. All three groups exhibited good response to pulse corticosteroids and showed a comparable functional outcome at 6-month follow-up.

The Role of Yoga in Hospitalized COVID-19 Patients: An Exploratory Randomized Controlled Trial.

Introduction The unpredictable course and sheer magnitude of coronavirus disease 2019 (COVID-19) have sparked a search for novel and repurposed pharmacological interventions. Non-pharmacological interventions may also play a role in the management of this multifaceted disease. This study aimed to evaluate the safety, feasibility, and effect of yoga in hospitalized patients with moderate COVID-19. Methods Twenty patients satisfying the inclusion criterion were randomized (1:1 ratio) into Intervention and Control groups. Patients in the intervention arm performed a one-hour yoga session that included pranayama and Gayatri mantra (GM) chant for up to 14 days. Sessions were fully supervised by a trained yoga trainer via an online platform. Patients in both groups received the normal treatment as per national guidelines. Outcome parameters were recorded on the 14th day/end of the hospital stay. Results Yoga is safe and feasible in hospitalized patients with COVID-19. The decline of high-sensitivity C-reactive protein (hs-CRP) levels was significantly greater in the Intervention Group. Quality of life (QOL), depression, anxiety, and fatigue severity scale (FSS) showed a decline in both groups with a significant decline observed in FSS scores of the Intervention Group. Median chest X-ray score values, duration of hospital stay, and reverse transcription-polymerase chain reaction (RT-PCR) conversion days were observed to be lower in the Intervention Group but were not significant (p>0.05). Conclusion The study found that incorporating pranayama and GM practices in hospitalized patients with moderate COVID-19 pneumonia was safe and feasible. It showed a notable reduction in hs-CRP levels and FSS scores in the Intervention Group, but the study was not powered to detect statistically significant results. Further research with larger sample sizes is needed for conclusive findings.

Magnetic resonance imaging brain yield in developmental delay: A developing country perspective.

BACKGROUND: Developmental delay (DD) is an important neuro-morbidity in children affecting the quality of life. MRI plays a crucial role by delineating the underlying structural, metabolic, and genetic abnormalities. AIM: To determine the yield of MRI brain in delineating the various underlying abnormalities and etiological factors in children with DD and to correlate these findings with the clinical presentation. METHODS: This cross-sectional study enrolled 50 children with the developmental delay between 6 months to 6 years of age. OUTCOMES AND RESULTS: The mean age was 31.32 ± 20.56 months. The sensitivity of MRI was 72%. 81.3% of the children with microcephaly had abnormal MRI. The most common underlying etiology was hypoxic-ischemic encephalopathy (42%), followed by congenital/developmental defects and metabolic diseases (10% each). The most commonly involved region of the cerebral cortex was the occipital lobe (44%) because of the high occurrence of coexisting hypoglycemic brain injury, which is extremely common in developing countries and rare in developed countries, with 80% of them having visual abnormalities. Frontal lobe involvement was significantly more in children with abnormal motor findings and behavioral changes. Cortical grey matter abnormalities were significantly more in children with seizures. CONCLUSION AND IMPLICATIONS: It is to be emphasized that children with developmental delays should be evaluated with MRI whenever possible. Apart from hypoxic-ischemic encephalopathy, other etiologies should also be looked for.

Multiparametric evaluation of bone tumors utilising diffusion weighted imaging and dynamic contrast enhanced magnetic resonance imaging.

Aim: This study aimed to use multiparametric magnetic resonance imaging (MRI) techniques, namely, diffusion-weighted imaging (DWI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to evaluate bone tumors. Methods: Thirty-three patients with primary untreated bone tumors were assessed utilizing DWI and DCE-MRI. Various parameters like ADC values from DWI and percentage peak signal intensity (%PSI), the maximum slope of increase (MSI), and time to peak signal intensity (TTP) values were assessed in different cases, and the final correlation was drawn with histopathological findings. Result: Parameters of semi-quantitative DCE-MRI, i.e., %PSI, MSI and, TTP, correlated significantly with the histopathological characteristics of the tumor (p values < 0.001). Minimum ADC value in the tumor also showed a strong correlation with the tumor characteristic (p values < 0.001). Also, the correlation between parameters of DWI and DCI-MRI is well correlated with each other. Conclusion: The results of this study provide grounds for the integration of multiparametric pre-treatment evaluation of bone tumors. In our study, we not only tried to utilize different parameters of functional MRI in bone tumors as well as re-explored the semi-quantitative analysis of DCE-MRI.

Vertebral arteriovenous fistula in neurofibromatosis type 1.

INTRODUCTION: Vertebral arterio-venous fistulas (VAVFs) are uncommon lesions that can arise spontaneously or secondarily to iatrogenic or mechanical trauma. Among spontaneous cases, it is most commonly found to be associated with neurofibromatosis type 1 (NF1). EVIDENCE ACQUISITION: We performed a systematic review of the literature to obtain information regarding demographics, clinical presentation, treatment modalities and outcome of VAVFs associated with NF1. A literature search was performed by using databases PubMed Central, Embase, Cochrane Library, and Ovid MEDLINE. Also, the grey area search was done using the "Google Scholar" search engine. On screening of the original full-text English language articles, a total of 48 cases were considered suitable for inclusion in this review. EVIDENCE SYNTHESIS: VAVFs in NF1 commonly present between 3rd and 6th decade of life affecting females 2.4 times more than males. Left-sided fistulae were more common than the right side and most seen in the upper V2 segment of the vertebral artery. Most VAVFs in NF 1 patients were treated with constructive (occlusion of fistula only) endovascular therapy (N.=26) with a high success rate. Moreover, pooled proportion of the outcome data have shown significant difference between the endovascular constructive and destructive procedure. CONCLUSIONS: The spontaneous VAVF, commonly associated with NF-1, often requires treatment. Awareness of the coexistence between NF1 and VAVF is crucial to avoid diagnostic delays and unnecessary surgical intervention leading to disastrous outcomes. Endovascular treatment is the preferred treatment approach while open surgical treatment is required in some complex fistulae and failure of endovascular techniques.

Clinicoradiological Predictors of Severity of Traumatic Intra-Abdominal Injury in Pediatric Patients: A Retrospective Study.

Background Adequate assessment of traumatic injury in patients of all age groups is essential for timely intervention and prevention of mortality and morbidity. This study aimed to assess the value of certain clinical as well as radiological factors as predictors of severity of the intra-abdominal injury as detected on computed tomography (CT) and to review the guidelines, protocols, and practices followed in imaging of abdominal trauma in patients of pediatric age group. Methods This retrospective observational study included 263 pediatric patients (18 years of age or younger) who presented to the emergency department (ED) with a history of trauma to the abdomen. The study was conducted over a period of 12 months. Correlation of five variables, i.e., age of the child, focused abdominal sonography in trauma (FAST) status, mechanism of injury, presenting complaints and clinical features (hypotension, tachycardia, etc), fractures identified on trauma X-ray series, was done with CT findings (severity of injury). All five variables were statistically analyzed and p-values were derived for age, mechanism of injury, presenting complaints, clinical features, and trauma x-ray series, while parameters like sensitivity and specificity were determined for FAST status Results All variables well correlated with the severity of injury with p-values <0.05. On multivariate analysis, FAST status had the highest (47.94) odds ratio among the five variables for predicting severe intra-abdominal injury while vital signs had the lowest (0.076). Further, age group of 0-4 years was found most prone to higher grades of injury with odds ratio of 7.83. Motor vehicle crash had odds ratio of 26.6 for severe injury, the highest among mechanisms of injury. While for FAST status, sensitivity was found to be 89.4%, specificity 85%, and negative predictive value 90%, trauma series radiographs had a sensitivity of 42.27%, specificity of 77.85% and negative predictive value of 60.55%. Conclusion Clinical parameters and traditional imaging techniques can predict the severity of injury on CT and guide further imaging and intervention.

A Rare Case of Primary Pleural Neurofibroma.

Metastatic deposits are the most common cause of pleural masses, solitary or multiple. Primary pleural neoplasms are rare entities that are occasionally encountered. Of these, the tumors of neurogenic origin are exceedingly rare with only a few cases reported in the literature. We describe a case of an isolated neurofibroma involving the pleura in a 23-year-old male patient, who underwent CT and MRI scans of the thorax as part of the initial investigations. The final diagnosis was clinched by a CT-guided biopsy of the lesion.

Magnetic Resonance Spectroscopy in Children With Developmental Delay: Time to Look Beyond Conventional Magnetic Resonance Imaging (MRI).

Developmental delay (DD) is an important long-term neuromorbidity owing to various insults to the developing brain and neuroimaging plays a key role in evaluating these children. Magnetic resonance spectroscopy (MRS) is the only noninvasive method to determine the levels of various metabolites in the brain which aids in delineating the underlying abnormalities. A total of 48 children aged between 6 months to 6 years with developmental delay were included and evaluated with neuroimaging in our study. Sensitivity of MRS in children with DD and DD plus (DD along with seizures, abnormal motor findings, behavior, brainstem evoked response audiometry, visual assessment, and microcephaly) was 81.2% and 89.6% respectively. 86.6% of children with microcephaly had abnormal MRS. MRS detected abnormalities in two-thirds of children with normal magnetic resonance imaging (MRI). Children with behavioral abnormalities had significantly lower N-acetyl aspartate (NAA)-creatine and NAA-choline ratios on MRS. Thus, MRS is additive to MRI in delineating the underlying pathophysiology in children with DD.

Unusual complication of colonic carcinoma: colonopleurobronchial fistula.

Colonopleurobronchial fistula (CPBF) is a rare complication which occurs due to diversified causes. Expectoration of the faecal material is the classical clinical symptom which suggests the diagnosis. Various causes include infection of pulmonary or abdominal origin, inflammatory bowel disease, colonic malignancy, diaphragmatic hernia and colonic interposition. Crohn's disease is the frequent underlying pathology, colonic malignancy accounts for rare cause. Due to the presence of liver in right upper quadrant, most of the fistulas are on the left side. Here we describe a rare case of a 38-year-old man presented with right-sided CPBF due to underlying colonic malignancy. Bronchial block was done, however the patient succumbed to death.