Use of the Posterior Lumbar Approach for Psoas Major Injection in Hip Flexor Spasticity.

BACKGROUND: Hip flexor spasticity in patients with upper motor neuron syndrome of multiple etiologies has been managed with botulinum neurotoxin injections mainly targeting the "iliopsoas" muscle. A lumbar approach to target psoas major (PM) has been described; however, it has not been incorporated into clinical practice due to perceived risk of injury to surrounding structures. This study will investigate the feasibility and accuracy of ultrasound-guided (UG)-PM injection using a lumbar approach by assessing the intra/extramuscular injectate spread in cadaveric specimens. METHODS: In eight lightly embalmed specimens, toluidine blue dye/saline was injected into PM using a UG-posterior lumbar approach. The posterior abdominal wall was exposed, and dye spread and surrounding structures digitized and modeled in 3D. The area and vertebral level of dye spread, distance of dye to the inferior vena cava (IVC), and abdominal aorta (AA) and dye spread to adjacent organs were quantified. RESULTS: The models enabled visualization of the dye spread in 3D. Mean area of dye spread was 24.4 ± 2.8 cm2; most commonly between L2 and L4 vertebral levels. Mean distance of the dye to AA was 3.2 ± 1.2 cm and to IVC was 1.8 ± 0.4 cm. Dye spread remained intramuscular in all but one specimen. No dye spread occurred to any adjacent organs. CONCLUSIONS: The injection of PM using the UG-posterior lumbar approach was consistent and without spread to surrounding structures. This technique alone or in addition to the anterior approach is expected to have better clinical outcomes in the treatment of hip flexor spasticity. Further clinical studies are required.

A Delphi-Based Consensus Statement on the Management of Anticoagulated Patients With Botulinum Toxin for Limb Spasticity.

OBJECTIVE: To create a consensus statement on the considerations for treatment of anticoagulated patients with botulinum toxin A (BoNTA) intramuscular injections for limb spasticity. DESIGN: We used the Delphi method. SETTING: A multiquestion electronic survey. PARTICIPANTS: Canadian physicians (N=39) who use BoNTA injections for spasticity management in their practice. INTERVENTIONS: After the survey was sent, there were e-mail discussions to facilitate an understanding of the issues underlying the responses. Consensus for each question was reached when agreement level was ≥75%. MAIN OUTCOME MEASURES: Not applicable. RESULTS: When injecting BoNTA in anticoagulated patients: (1) BoNTA injections should not be withheld regardless of muscles injected; (2) a 25G or smaller size needle should be used when injecting into the deep leg compartment muscles; (3) international normalized ratio (INR) level should be ≤3.5 when injecting the deep leg compartment muscles; (4) if there are clinical concerns such as history of a fluctuating INR, recent bleeding, excessive or new bruising, then an INR value on the day of injection with point-of-care testing or within the preceding 2-3 days should be taken into consideration when injecting deep compartment muscles; (5) the concern regarding bleeding when using direct oral anticoagulants (DOACs) should be the same as with warfarin (when INR is in the therapeutic range); (6) the dose and scheduling of DOACs should not be altered for the purpose of minimizing the risk of bleeding prior to BoNTA injections. CONCLUSIONS: These consensus statements provide a framework for physicians to consider when injecting BoNTA for spasticity in anticoagulated patients. These consensus statements are not strict guidelines or decision-making steps, but rather an effort to generate common understanding in the absence of evidence in the literature.

Skin Diseases in Patients With Primary Psychiatric Conditions in Northern India: A Cross-Sectional Study.

BACKGROUND: The relationship between skin diseases and psychiatric illnesses is bi-directional and is manifested as cause and effect. Psychiatric disorders such as stress, anxiety, and depression are seen to be instrumental in the development and progression of dermatological diseases on one hand, while on the other hand, cosmetic disfigurement caused by dermatological diseases is responsible for psychological distress in patients. The present study was conducted to investigate the spectrum of dermatological disorders in psychiatric patients to offer them holistic treatment and provide them with a better quality of life. METHODS: This cross-sectional, observational study was conducted at a tertiary medical care center. A total of 170 psychiatric patients referred to the dermatology department for different dermatological manifestations were enrolled in the study. A demographic profile of the patients was done, and an association between dermatological diseases and psychiatric illnesses was done. RESULTS:  Out of 170 study participants, 88 (51.8%) were females, and the rest (82, 48.2%) were males. A total of 13 major types of dermatological conditions were noted; among them, fungal infection (43, 25.3%) was the most common, followed by eczema (18, 10.6%), parasitic infestation (17, 10.0%), pigmentary disorder (13, 7.6%), acne (11, 6.5%), bacterial infection (11, 6.5%), pruritic disorder (11, 6.5%), hair disorder (9, 5.3%), drug reaction (9, 5.3%), papulosquamous disorder (7, 4.1%), and viral infection (6, 3.5%). Skin conditions other than the above-mentioned were present in 15 (8.8%) patients. The most common psychiatric illness in the present study was major depressive disorder (41, 24.1%), followed by generalized anxiety disorder (38, 22.4%) and psychosis not otherwise specified (34, 20.0%). Other psychiatric illnesses included in the study were bipolar affective disorder (22, 12.9%), schizophrenia (18, 10.6%), obsessive-compulsive disorder (12, 7.1%), and mixed anxiety depressive disorder (5, 2.9%). CONCLUSION: The findings of the present study depict that psychiatric patients with dermatological manifestations show a spectrum of dermatological conditions, primarily of infectious (fungal, parasitic, or viral) nature. This might be associated with a relatively poor hygienic status of psychiatric patients and thus their increased susceptibility to these disorders. Most of the time, the susceptibility to these skin conditions seemed to be opportunistic and unaffected by the type, duration, and level of control of psychiatric illness.

A Survey-Based Assessment of Awareness Regarding Parthenium hysterophorus in a Rural Population of North India.

Background Parthenium hysterophorus is a poisonous weed that has spread across the length and breadth of the Indian subcontinent. It is a common cause of dermatitis similar to other members of the family, such as ragweeds in the United States and chrysanthemums in Europe. Despite the common occurrence of the plant in the environment, the general population does not seem to be aware of its adverse effects. This cross-sectional study was conducted with the aim of assessing the awareness of P. hysterophorus in the local rural population. Methodology A questionnaire was designed by an expert panel consisting of three dermatologists after a bibliological survey and collection of published literature on P. hysterophorus. All adult patients >18 years of age approaching the outpatient department of dermatology at our tertiary health care center were included in a consecutive sampling manner. Patients with an unsound mind or those who refused to provide consent were excluded from the study. Results A total of 250 patients participated in the study, of whom 56.8% were male and 43.2% were female, with ages ranging from 18 to 80 years. The majority of the participants were farmers by occupation. Three-fourths of the participants (187, 74.8%) were able to identify the plant. Maximum participants (144, 57.6%) did not know about the ill effects of Parthenium, and 148 (59.2%) did not know about the method of controlling its spread. Conclusions The study was conducted among 250 respondents from a rural community in North India. Despite almost 75% of participants identifying the weed, more than half were neither aware of its ill effects nor knew about the methods of control. Furthermore, most participants were educated individuals yet remained ignorant. Emphasis needs to be made on awareness campaigns about the fast-spreading Parthenium and its ill effects.

Supply chain vulnerability assessment for manufacturing industry.

In today's business, environment natural and manmade disasters like recent event (Covid 19) have increased the attention of practitioners and researchers to Supply chain vulnerability. Purpose of this paper is to investigate and prioritize the factors that are responsible for supply chain vulnerability. Extant literature review and interviews with the experts helped to extract 26 supply chain vulnerability factors. Further, the relative criticality of vulnerability factors is assessed by analytical hierarchy process (AHP). Critical part supplier; location of supplier; long supply chain lead times; Fixing process owners and mis-aligned incentives in supply chain are identified as the most critical factors among twenty-six vulnerability factors. Research concludes that not only long and complex supply chain but supply chain practices adopted by firms also increase supply chain vulnerability. Relative assessment of vulnerability factors enables professionals to take appropriate mitigation strategies to make the supply chains more robust. This research adds in building a model for vulnerability factors that are internal to supply chain & controllable.

Gene expression patterns regulating the seed metabolism in relation to deterioration/ageing of primed mung bean (Vigna radiata L.) seeds.

We are proposing mechanisms to account for the loss of viability (seed deterioration/ageing) and enhancement in seed quality (post-storage priming treatment). In order to understand the regulatory mechanism of these traits, we conducted controlled deterioration (CD) test for up to 8 d using primed mung bean seeds and examined how CD effects the expression of many genes, regulating the seed metabolism in relation to CD and priming. Germination declined progressively with increased duration of CD, and the priming treatment completely/partially reversed the inhibition depending on the duration of CD. The loss of germination capacity by CD was accompanied by a reduction in total RNA content and RNA integrity, indicating that RNA quantity and quality impacts seed longevity. Expression analysis revealed that biosynthesis genes of GA, ethylene, ABA and ROS-scavenging enzymes were differentially affected in response to duration of CD and priming, suggesting coordinately regulated mechanisms for controlling the germination capacity of seeds by modifying the permeability characteristics of biological membranes and activities of different enzymes. ABA genes were highly expressed when germination was delayed and inhibited by CD. Whereas, GA and ethylene genes were more highly expressed when germination was enhanced and permitted by priming under similar conditions. GSTI, a well characterized enzyme family involved in stress tolerance, was expressed in primed seeds over the period of CD, suggesting an additional protection against deterioration. The results are discussed in light of understanding the mechanisms underlying longevity/priming which are important issues economically and ecologically.

Functional goal achievement in post-stroke spasticity patients: the BOTOX® Economic Spasticity Trial (BEST).

OBJECTIVE: Evaluate changes in active and passive function with onabotulinumtoxinA + standard of care within goal-oriented rehabilitation programmes in adults with focal post-stroke spasticity. METHODS: Prospective, 24-week double-blind study with an open-label extension. Subjects were randomized to onabotulinumtoxinA + standard of care or placebo + standard of care, at baseline and at 12 weeks, if judged appropriate, with follow-up to 52 weeks. The primary endpoint was the number of patients achieving their principal active functional goal at 24 weeks (or 10 weeks after an optional second injection). Secondary endpoints included achievement of a different active or a passive goal at this timepoint. RESULTS: The intent-to-treat population comprised 273 patients. The proportion of patients achieving their principal active functional goal and secondary active functional goal with onabotulinumtoxinA + standard of care was not statistically different from placebo + standard of care. Significantly more patients achieved their secondary passive goal with onabotulinumtoxinA + standard of care (60.0%) vs. placebo + standard of care (38.6%) (odds ratio, 2.46; 95% confidence interval, 1.18-5.14) as well as higher Goal Attainment Scaling levels for upper limb and ankle flexor subgroups. CONCLUSIONS: Addition of onabotulinumtoxinA to standard of care as part of goal-oriented rehabilitation in post-stroke spasticity patients significantly increased passive goal achievement and was associated with higher levels of active function.

Stem cell transplantation: brief review and current status.

In recent years stem cell has come up as a great advance in therapy for a number of illnesses and has potential for revolutionising the medical field. Right from myelodysplastic syndrome to amyloidosis it has been tried. The present review is a modest endeavour to acquaintain in brief about current status of stem cells.

Acute respiratory distress syndrome.

INTRODUCTION: Acute respiratory distress syndrome (ARDS) is characterised by lung inflammation with severe hypoxia, which usually develops over 4-48 hours and persists for days or weeks. The main causes of ARDS are infections, aspiration of gastric contents, and trauma. Between a third and a half of people with ARDS die from the disease, but mortality depends on the underlying cause. Some survivors have long-term respiratory or cognitive problems. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of interventions in adults with acute respiratory distress syndrome? We searched: Medline, Embase, The Cochrane Library and other important databases up to August 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 21 systematic reviews, RCTs, or observational studies that met our inclusion criteria. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: corticosteroids, low tidal volume mechanical ventilation, nitric oxide, prone position, and protective ventilation.

Evaluation of the efficacy and safety of levalbuterol in subjects with COPD.

The efficacy and safety of nebulized levalbuterol in adults with chronic obstructive pulmonary disease (COPD) was evaluated in this multicenter, randomized, double-blind, parallel design study. Randomized subjects (n = 209) received levalbuterol (LEV) 0.63 mg or 1.25 mg, racemic albuterol (RAC) 2.5 mg, or placebo (PBO) TID for 6 weeks. Serial spirometry was completed in-clinic after study drug alone (weeks 0, 2, and 6) or in combination with ipratropium bromide 0.5 mg (week 4). The primary endpoint was the averaged FEV1 AUC(0-8 hrs) over weeks 0, 2 and 6 compared with placebo. Other endpoints included rescue medication use, safety parameters, COPD exacerbations, and global evaluations. All active treatments demonstrated improvements in the percent change in FEV1 AUC(0-8 hrs) over the double-blind period and at each visit vs PBO (p < 0.05). Rescue medication use vs. baseline (doses/day) changed over time: PBO +0.38 +/- 3.3; LEV 0.63 mg +0.07 +/- 3.3; LEV 1.25 mg -0.84 +/- 3.8 (p = 0.02 vs. RAC); RAC +0.97 +/- 2.5. The overall rate of adverse events was PBO 56.4%, LEV 0.63 mg 56.6%, LEV 1.25 mg 67.3%, and RAC 65.4%. Protocol-defined COPD exacerbations occurred in all groups (PBO 12.7%, LEV 0.63 mg 11.3%; LEV 1.25 mg 18.4%; RAC 21.2%). Withdrawals due to COPD exacerbations were significantly higher in the RAC group compared with PBO (PBO 0%; LEV 0.63 mg 1.9%; LEV 1.25 mg 4.1%; RAC 9.6% p = 0.01 vs. PBO). In this study, levalbuterol treatment in subjects with COPD was generally well tolerated, produced significant bronchodilation compared with PBO, and improved clinical control of COPD as evidenced by reductions in rescue medication use compared with PBO and/or RAC.

Aneurysmal bone cyst of paranasal sinuses.

Aneurysmal hone cyst is rare in paranasal sinuses. It may be uni or multilocutar It occurs alone or with other benign bone lesions. The exact pathogenesis of it is still unknown. The aggressiveness of the disease needs early diagnosis and proper management to prevent recurrence. This report describes a case of aneurysmal bone cyst involving the ethmoid and maxillary sinuses which was successfully managed.

Inverted papilloma of nose with orbital involvement and malignant transformation.

We report two cases of inverted papilloma of nose with malignant transformation and orbital involvement in 60 year and 73 year male patients from Nepal. Medial maxillectomy and orbital exenteration were done in both cases. Histo- pathological examination showed areas of squamous cell carcinoma in inverted papilloma in both of the cases.The dilemma of diagnosis and treatment is discussed with review of literature.