Ultralow-Dose Dynamic Expiratory CT and Repeated Imaging Enhance Evaluation for Tracheomalacia.

OBJECTIVE: This study aims to determine if a novel imaging protocol (ultralow-dose dynamic expiratory computed tomography [CT] with repeated imaging) identifies tracheomalacia (TM) more reliably than traditional dynamic tracheal CT. METHODS: We performed a retrospective evaluation of 184 consecutive ultralow-dose dynamic CTs for TM during 2017. The protocol obtains images during 1 inspiration and 2 forced expirations. Tracheal narrowing during both expirations (airway narrowing [percentage] during first dynamic expiration CT [DE1], airway narrowing [percentage] during second dynamic expiration CT [DE2]) was reported as a percentage of inspiratory area. We identified maximum narrowing of each patient's sequence (maximum narrowing [percentage] on either dynamic expiration CT [DEmax] = greatest narrowing of DE1 or DE2) and compared DE1, DE2, and DEmax in individual studies and between patients. Outcomes included frequency of TM, tracheal narrowing, and severity. Reliability was assessed by comparing tracheal area narrowing and TM grade. RESULTS: There was significantly more airway narrowing using 2 expiratory image acquisitions. Average DEmax tracheal area was 12% narrower than DE1 alone and 21% worse than DE2 alone (both P < 0.001). Using DEmax, TM was diagnosed 35% more often than DE1 alone and 31% more often than DE2 alone ( P < 0.001). DEmax identified more severe distribution of TM compared with DE1 or DE2 alone ( P < 0.001). Reliability between DE1 and DE2 was good for tracheal narrowing and moderate for TM grade. The mean effective radiation dose was 2.41 millisievert (mSv) for routine inspiration CT and 0.07 mSv for each dynamic expiration CT (total effective radiation, 2.55 mSv). CONCLUSIONS: Dynamic expiration CT with 2 expiratory image acquisitions enhanced evaluation of TM, minimally increased radiation dose, and should be considered as a noninvasive screening option.

Cost of implementing the QualityRights programme in public hospitals in Gujarat providing mental healthcare.

Background & objectives: Investment in mental health is quite meagre worldwide, including in India. The costs of new interventions must be clarified to ensure the appropriate utilization of available resources. The government of Gujarat implemented QualityRights intervention at six public mental health hospitals. This study was aimed to project the costs of scaling up of the Gujarat QualityRights intervention to understand the additional resources needed for a broader implementation. Methods: Economic costs of the QualityRights intervention were calculated using an ingredients-based approach from the health systems' perspective. Major activities within the QualityRights intervention included assessment visits, meetings, training of trainers, provision of peer support and onsite training. Results: Total costs of implementing the QualityRights intervention varied from Indian Rupees (₹) 0.59 million to ₹ 2.59 million [1United States Dollars (US $) = ₹ 74.132] across six intervention sites at 2020 prices with 69-79 per cent of the cost being time cost. Scaling up the intervention to the entire State of Gujarat would require about two per cent increase in financial investment, or about 7.5 per cent increase in total cost including time costs over and above the costs of usual care for people with mental health conditions in public health facilities across the State. Interpretation & conclusions: The findings of this study suggest that human resources were the major cost contributor of the programme. Given the shortage of trained human resources in the mental health sector, appropriate planning during the scale-up phase of the QualityRights intervention is required to ensure all staff members receive the required training, and the treatment is not compromised during this training phase. As only about two per cent increase in financial cost can improve the quality of mental healthcare significantly, the State government can plan for its scale-up across the State.

Systematic evaluation of the QualityRights programme in public mental health facilities in Gujarat, India.

BACKGROUND: Recognising the significant extent of poor-quality care and human rights issues in mental health, the World Health Organization launched the QualityRights initiative in 2013 as a practical tool for implementing human rights standards including the United Nations Convention on Rights of Persons with Disabilities (CRPD) at the ground level. AIMS: To describe the first large-scale implementation and evaluation of QualityRights as a scalable human rights-based approach in public mental health services in Gujarat, India. METHOD: This is a pragmatic trial involving implementation of QualityRights at six public mental health services chosen by the Government of Gujarat. For comparison, we identified three other public mental health services in Gujarat that did not receive the QualityRights intervention. RESULTS: Over a 12-month period, the quality of services provided by those services receiving the QualityRights intervention improved significantly. Staff in these services showed substantially improved attitudes towards service users (effect sizes 0.50-0.17), and service users reported feeling significantly more empowered (effect size 0.07) and satisfied with the services offered (effect size 0.09). Caregivers at the intervention services also reported a moderately reduced burden of care (effect size 0.15). CONCLUSIONS: To date, some countries are hesitant to reforming mental health services in line with the CRPD, which is partially attributable to a lack of knowledge and understanding about how this can be achieved. This evaluation shows that QualityRights can be effectively implemented even in resource-constrained settings and has a significant impact on the quality of mental health services.

A contemporary review of radiation pneumonitis.

PURPOSE OF REVIEW: The current article reviews recent literature and summarizes the current understanding, diagnosis, risk, predictors, and management of radiation pneumonitis. RECENT FINDINGS: We discuss the different parameters that contribute to radiation toxicity, the potential biomarkers that predict the risk, and mitigators of radiation pneumonitis. SUMMARY: Radiotherapy aims to provide care and a better quality of life in cancer patients however with complications. Radiation pneumonitis is important to recognize to appropriately plan and care for this population.

Complications of Intravesical BCG Immunotherapy for Bladder Cancer.

An earlier incorrect version appeared online. This article was corrected on December 14, 2018.

Ultralow Dose Dynamic Expiratory Computed Tomography for Evaluation of Tracheomalacia.

OBJECTIVE: The aim of this study was to determine the average effective radiation dose and feasibility of ultralow dose dynamic expiratory computed tomography (CT) for evaluation of tracheomalacia (ULD) and to evaluate factors that impact image quality. METHODS: This is a retrospective study of 64 consecutive patients from September to October 2016 for the evaluation of tracheomalacia. All studies were performed with routine inspiration chest CT followed by ULD z(kilovoltage peak (kVp) 80, 100, or 120 and fixed milliamperage 10) or typical dose CT (TD) (kVp 100 or 120 with automated milliamperage) dynamic expiration CT. Image quality was considered diagnostic if the trachea area could be accurately measured for tracheomalacia assessment, and diagnostic studies were graded fair, good, or excellent. Scan length, image quality, and effective radiation dose were compared for ULD versus TD and ULD at 100 kVp versus ULD at 80 kVp. For ULD studies, patient factors were compared across image quality. RESULTS: The ULD had a mean effective radiation dose of 0.08 mSv, with all studies of diagnostic image quality. The ULD showed 95% reduction in effective radiation dose (P < 0.001), 14% significant reduction in scan length (P = 0.029), and qualitatively decreased image quality compared w2 ith TD (P < 0.001). The ULD at 100 kVp had significantly better image quality compared with ULD at 80 kVp (P = 0.041) with higher effective radiation dose (0.09 vs 0.05 mSv) (P < 0.001). Body mass index significantly impacted image quality for all ULD studies but not for ULD at 80 or 100 kVp. CONCLUSION: For evaluation of tracheomalacia, ULD showed low effective radiation dose less than 0.1 mSv and maintained diagnostic image quality.

Multiple pulmonary nodules in malignancy.

PURPOSE OF REVIEW: Multiple pulmonary nodules are a common finding especially with the implementation of lung cancer screening. Available guidelines address the management of solitary pulmonary nodules. The management of the multiple pulmonary nodules would differ based on the characteristic of the nodules, their distribution, and the history of the patients as well. RECENT FINDINGS: Most of the recent publications on multiple pulmonary nodules consist of individual case reports or case series. Robust population studies are lacking. SUMMARY: In this article, we propose an approach for management of multiple pulmonary nodules which needs to be validated.

Update in primary pulmonary lymphomas.

PURPOSE OF REVIEW: Despite the fact that primary pulmonary lymphoma (PPL) is a rare lung tumour, significant advances addressing clinical features, histological diagnosis, prognostic criteria and therapeutic management of this disease have been made within the past decade. RECENT FINDINGS: Monoclonality and phenotyping of alveolar lymphocytes are suggestive of mucosa-associated lymphoid tissue (MALT). Detection of MALT-1 gene rearrangements in bronchoalveolar fluid cells using fluorescence in-situ hybridization techniques helps to confirm the diagnosis of MALT PPL. Fine needle aspiration-computed tomography guided biopsies as well as transbronchial/cryobiopsies provide adequate tissue material for histological evaluation. Recent publications also provide a better appreciation of newer chemotherapeutic approaches, including fludarabine and mitoxantrone with or without ritubximab for the treatment of MALT, as well as complete surgical resection if local disease is present. Prognostic factors influencing survival and optimal therapy for MALT have not been well defined, but the use of tumour microvascular density appears promising. SUMMARY: This review outlines the implications of recent findings for clinical practice and research progress of PPL. Larger, multicentre and well designed studies are imperative to optimize the current diagnostic and therapeutic approach for this disease.

Anatomic considerations for posterior iliac crest bone procurement.

PURPOSE: The aim of this study was to identify the relative anatomic locations of relevant vital structures at risk for injury during posterior iliac crest bone graft procurement. MATERIALS AND METHODS: Twenty-one cadavers yielded 39 intact posterior ilia for dissection. The posterior superior iliac spine (PSIS) was used as the primary reference landmark. Measurements were made to the medial branch of the superior cluneal nerves, the superior branch of the middle cluneal nerves, the sciatic notch, and the superior gluteal vessels. Distances from the spinal midline to the superior cluneal nerves were recorded. RESULTS: The average distances from the PSIS to the superior and middle cluneal nerves, greater sciatic notch, and superior gluteal vessels were 5.7 cm (standard deviation, 1.22 cm), 6.55 cm (standard deviation, 1.53 cm), 5.3 cm (standard deviation, 0.71 cm), and 5.4 cm (standard deviation, 0.95 cm), respectively. The most medial superior cluneal nerve was identified at 3.0 to 4.9 cm from the PSIS in 23% of cases, at 5.0 to 6.9 cm from the PSIS in 61.5% of cases, and farther than 7.0 cm from the PSIS in 15.4% of cases. CONCLUSIONS: This study illustrates that the most medial superior cluneal nerve is often closer to the PSIS than previously described and the same holds true for the greater sciatic notch and superior gluteal vessels. Knowledge of the anatomic locations of these important structures should allow the surgeon to avoid or decrease the complication rate of bone procurement from the posterior ilium.

Comparative Evaluation of Intranasal Dexmedetomidine Spray Versus Intranasal Normal Saline Spray in Patients Undergoing Transalveolar Extractions for Anxiety Reduction: A Randomized Control Study.

Background: Dexmedetomidine has dose-dependent selectivity for alpha 2 adrenoceptors. It is a good sedative with analgesic characteristics and good haemodynamic stability. Intranasal sedation is a non-invasive medication delivery method that is both safe and well accepted by both children and adults. One of the most common procedures in maxillofacial surgery is transalveolar extraction. In minor oral surgery, a painless transalveolar extraction with little post-operative pain would be ideal. Aim: To examine the effectiveness of intranasal dexmedetomidine spray against intranasal normal saline spray in patients undergoing transalveolar extractions for anxiety relief. Method: We compared sedation effect by Ramsay sedation scale, analgesia by visual analogue scale, monitored BP and pulse rate for anxiety, and spo2 levels for any complication in this prospective double-blinded randomized control study for two groups, A group with intranasal dexmedetomidine spray and the B group of intranasal NS spray for placebo effect at 0 min, 15 min, 30 min, and 45 min until transalveolar extraction. Result: As a result of the intranasal spray of dexmedetomidine, there were no related problems such as respiratory depression. There was a substantial difference in sedation and analgesia between group A and the placebo group, as well as a significant decrease in pulse rate and hypotension in the dexmedetomidine group to reduce anxiety. Conclusion: Intranasal injection of atomized dexmedetomidine (1.5 mcg/kg) for patient sedation having transalveolar extractions or other minor surgical operations in oral and maxillofacial surgery is clinically effective, convenient, lowers anxiety, and safe.Clinical Trial Registration: No. CTRI/2021/07/035181.

A multidisciplinary approach to treating a unique case of recurrent metastatic thymic carcinoma: case report.

Thymic carcinoma (TC) is a rare and aggressive malignancy of the thymus associated with less than 25% 5 years survivability. Our case report showcases the successful treatment of advanced metastatic TC using a multidisciplinary approach and the utility of checkpoint inhibitors in treatment of recurrent TC. A 50-year-old man presented with Raynaud's phenomenon and was found to have a stage IVb TC (T3N2M0). Eight months after management with neoadjuvant chemotherapy, surgical resection and adjuvant chemoradiotherapy, patient was diagnosed with metastasis of TC to the liver and a concurrent stage III (T2N1M0) primary sigmoid colon adenocarcinoma. Following complete resection of the colon adenocarcinoma, the patient started palliative-intent treatment for TC with pembrolizumab given PD-L1 tumor proportionate score of 100%. This resulted in a sustained complete response for 38 months. Our patient did have immune-related adverse events involving multiple organs but was able to continue pembrolizumab for a standard treatment duration of 2 years with multidisciplinary care. When recurrent disease was noted in a portocaval lymph node, pembrolizumab was reinitiated and a second complete response was achieved. The patient has maintained that complete response while maintaining an acceptable quality of life, showing that treatment with pembrolizumab is effective in patients after discontinuation with prior immunotherapy.

Fighting Thymic Carcinoma: A Story of Immunotherapy and Multidisciplinary Care Triumph The thymus is a gland located in the chest that plays a major role in the immune system, particularly before adulthood. Thymic carcinoma (TC) is a type of cancer affecting the thymus that is often challenging to treat given its inadequate response to chemotherapy and tendency to spread to other organs. A 50-year-old man was found to have advanced stage thymic carcinoma, which is associated with a less than 25% 5-year survival rate. Eight months after completing a rigorous treatment protocol of chemotherapy, surgery and radiation therapy, his original thymic cancer was found to have metastasized to the liver. Simultaneously, he was diagnosed with stage III sigmoid colon cancer. He underwent curative surgery for colon cancer and was started on pembrolizumab for thymic cancer. Pembrolizumab is an immunotherapy drug that boosts the body's own immune system to fight against the cancer. Inadvertently, it can turn immune cells against healthy tissues, which results in symptoms called immune-related adverse events (irAEs). Indeed, he experienced various irAEs involving multiple organs. These events were effectively managed by involving multiple specialists and initiating medications to calm the immune system and allow him to continue immunotherapy. He had a complete response to treatment and was able to complete the standard treatment course of two years. He retained a complete response for over three years before his tumor recurred. He was restarted on pembrolizumab and achieved a complete response again. This case highlights a unique presentation of metastatic TC and the utility of a multidisciplinary approach for treatment to maintain a high quality of life five years after diagnosis.

The removal of single layers from multi-layer graphene by low-energy electron stimulation.

The removal of single atomic layers from multi-layer graphene using a He plasma is reported. By applying sample biases of -60 and +60 V during He plasma exposure, layer removal is found to be due to electrons instead of He ions or neutrals in the plasma. The rate of layer removal depends on exposure time, sample bias, and pre-annealing treatments. Optical contrast microscopy and atomic force microscopy studies show that the removal of C atoms occurs approximately one layer at a time across the entire multi-layer sample with no observable production of large pits or reduction in lateral dimensions. Layer removal is proposed to arise from the electron-stimulated dissociation of C atoms from the basal plane. This process differs from plasma techniques that use reactive species to etch multi-layer graphene.

Hypothyroidism in Thyroid Hemiagenesis: A Case Report.

Thyroid hemiagenesis is one of the rare developmental abnormalities of the thyroid. It is more common in women and more commonly found on the left side, often associated with the absence of isthmus. In most instances, thyroid hemiagenesis is presented with hyperthyroidism. This case report aimed to present a 72-year-old female who presents with thyroid hemiagenesis and associated hypothyroidism. She was initially diagnosed with hypothyroidism about 25 years ago. There was no family history of thyroid disease, and she never underwent any neck, thyroid, or parathyroid surgeries. Her most recent laboratory investigations revealed thyroid-stimulating hormone level of 0.93 mIU/ml, free tetraiodothyronine of 0.93 mcg/dl, free triiodothyronine of 2.75 ng/dl, anti-thyroid peroxidase of 2.0 IU/ml, and thyroid-stimulating immunoglobulin of less than 1.0 IU/l. An ultrasound study of her neck revealed an absence of the left thyroid lobe and isthmus. The diagnosis of congenital thyroid hemiagenesis with hypothyroidism was made, and the current treatment with 75 mcg of levothyroxine was continued. Thyroid hemiagenesis is an incidental finding and may present later in life. Thyroid hemiagenesis is commonly associated with hyperthyroidism, but it can present with hypothyroidism. Patients with thyroid hemiagenesis may be at higher risk for developing hypothyroidism than their normal counterparts due to smaller thyroid hormone reserves.

Utilization rate of corneal tissue obtained from donors over 75 years of age in Western India for keratoplasty.

PURPOSE: To examine the utilization patterns of cornea procured from diseased individuals ≥75 years of age at an eye bank in western India. METHODS: In this retrospective study, data from 1,217 eyes of 653 donors with age ≥75 years were reviewed from October 2008 to December 2019. Donor age, lens status, endothelial cell count (ECD), utilization of the tissue for transplantation or non-clinical purposes (e.g., research, training/discarded), and causes of non-utilization were noted. RESULTS: The mean age of the donors was 80.9 ± 4.6 years and the tissue utilization rate was 36.5% (445 out of 1,217 eyes). The eyes used for keratoplasty procedures had a lower donor age (79.6 ± 5.7 vs. 81.5 ± 5.1; P < 0.001), a higher endothelial cell count (2493 ± 531 vs. 2034 ± 581; P < 0.001), and were more often phakic (61% vs. 36.6%) compared to the unused group. A multivariable logistic regression analysis showed that the likelihood of tissue utilization for keratoplasty was 13% higher with every 100-cell increment in donor ECD (odds ratio [OR] = 1.13, 95% CI = 1.10-1.16, P < 0.001) and 33% lower with having a pseudophakic status in the donor eye (OR = 0.67, 95% CI = 0.52-0.87, P = 0.03). Age was not a significant determinant of tissue utilization when used in the same multivariable model. CONCLUSION: More than one-third of the eyes (36.5%) can be utilized even when the donors are above 75 years of age. Eyes that were more likely to be utilized for keratoplasty were phakic and had a significantly higher ECD; age was not a determinant in tissue utilization.

A Case of Subacute Thyroiditis following COVID-19 Infection.

Background/Objective. Since the start of the pandemic, COVID-19 has been associated with several postinfection complications. Subacute thyroiditis (SAT) is an inflammatory disorder of the thyroid that has been reported in the literature following COVID-19 infection. We report a case of SAT following COVID-19 infection. Case Report. A 33-year-old female presented with neck pain two weeks after resolution of COVID-19 infection. Her thyroid function tests together with ultrasonographic pictures were consistent with SAT. She was treated with three rounds of medrol dose pack without relief. She then required oral prednisone 40 mg per day and ibuprofen 800 mg once daily for another several weeks that eventually resulted in improvement of her symptoms. Discussion. SAT most commonly occurs in females during or after viral infection. The usual course of the disease is hyperthyroidism then hypothyroidism followed by resolution. SAT is clinically diagnosed by lab findings of decreased TSH in the setting of negative thyroid-stimulating and thyroid peroxidase antibodies. All these data are consistent with our case. Conclusion. SAT following COVID-19 infection presents with a similar clinical presentation and course as the classic form of SAT, but we should consider the fact that a high-dose corticosteroid treatment might be necessary for such patients.

Cardiac pseudoaneurysm as a complication of native mitral valve infective endocarditis.

BACKGROUND: The delayed development of a mitral valve annulus pseudoaneurysm is a rare and late complication of a native mitral abscess cavity. CASE SUMMARY: Currently, there are no documented cases of a pseudoaneurysm developing from an abscess cavity of the posterior annulus of the native mitral valve. We report a case of a patient who presented with worsening progressive shortness of breath that was found to be secondary to a pseudoaneurysm. This was detected by 2D echocardiogram and cardiac computed tomography angiography. DISCUSSION: In our case, the patient developed a late complication of a ventricular pseudoaneurysm originating from the mitral annular area of the abscess cavity. Per the surgical literature, one method to avoid the aforementioned complication is via cavity repair with a bovine patch.

Atrial Fibrillation among Patients Admitted to the Department of Internal Medicine in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

INTRODUCTION: Atrial fibrillation is one of the commonest arrhythmias with an overall prevalence estimated to be 0.4-1% in the general population. The objective of this study was to find out the prevalence of atrial fibrillation among patients admitted to the Department of Internal Medicine in a tertiary care centre. METHODS: A descriptive cross-sectional study was conducted among patients admitted to the Department of Internal Medicine of a tertiary care centre from 01 March 2021 to 01 March 2022. Ethical approval was obtained from the Institutional Review Committee (Reference number: IRC-478/2021). Convenience sampling method was used. Data were collected from the hospital records using a semi-structured study proforma including demography, clinical presentation, laboratory investigations, electrocardiogram, 2-dimension echocardiography, and CHA2DS2VASc score. Point estimate and 95% Confidence Interval were calculated. RESULTS: Among 27,980 patients, atrial fibrillation was found in 185 (0.66%) (0.58-0.77, 95% Confidence Interval). Among them 66 (35.67%) were in the age group of 61-70 years and 97 (52.43%) were females. Dyspnea was present in 149 (80.54%), palpitation in 137 (74.05%) and pedal edema in 117 (63.27%). Valvular atrial fibrillation was seen in 101 (54.59%) and non-valvular atrial fibrillation was seen in 84 (45.41%) patients. CONCLUSIONS: The prevalence of atrial fibrillation was found to be similar when compared to other studies conducted in similar settings.

Algorithmic Approach to the Diagnosis of Organizing Pneumonia: A Correlation of Clinical, Radiologic, and Pathologic Features.

Organizing pneumonia (OP), characterized histopathologically by patchy filling of alveoli and bronchioles by loose plugs of connective tissue, may be seen in a variety of conditions. These include but are not limited to after an infection, drug reactions, radiation therapy, and collagen vascular diseases. When a specific cause is responsible for this entity, it is referred to as "secondary OP." When an extensive search fails to reveal a cause, it is referred to as "cryptogenic OP" (previously called "bronchiolitis obliterans with OP"), which is a clinical, radiologic, and pathologic entity classified as an interstitial lung disease. The clinical presentation of OP often mimics that of other disorders, such as infection and cancer, which can result in a delay in diagnosis and inappropriate management of the underlying disease. The radiographic presentation of OP is polymorphous but often has subpleural consolidations with air bronchograms or solitary or multiple nodules, which can wax and wane. Diagnosis of OP sometimes requires histopathologic confirmation and exclusion of other possible causes. Treatment usually requires a prolonged steroid course, and disease relapse is common. The aim of this article is to summarize the clinical, radiographic, and histologic presentations of this disease and to provide a practical diagnostic algorithmic approach incorporating clinical history and characteristic imaging patterns.

Stable aqueous dispersions of noncovalently functionalized graphene from graphite and their multifunctional high-performance applications.

We present a scalable and facile technique for noncovalent functionalization of graphene with 1-pyrenecarboxylic acid that exfoliates single-, few-, and multilayered graphene flakes into stable aqueous dispersions. The exfoliation mechanism is established using stringent control experiments and detailed characterization steps. Using the exfoliated graphene, we demonstrate highly sensitive and selective conductometric sensors (whose resistance rapidly changes >10,000% in saturated ethanol vapor), and ultracapacitors with extremely high specific capacitance (∼ 120 F/g), power density (∼ 105 kW/kg), and energy density (∼ 9.2 Wh/kg).