MyoVision-US: an Artificial Intelligence-Powered Software for Automated Analysis of Skeletal Muscle Ultrasonography.

Introduction/Aims: Muscle ultrasound has high utility in clinical practice and research; however, the main challenges are the training and time required for manual analysis to achieve objective quantification of morphometry. This study aimed to develop and validate a software tool powered by artificial intelligence (AI) by measuring its consistency and predictability of expert manual analysis quantifying lower limb muscle ultrasound images across healthy, acute, and chronic illness subjects. Methods: Quadriceps complex (QC [rectus femoris and vastus intermedius]) and tibialis anterior (TA) muscle ultrasound images of healthy, intensive care unit, and/or lung cancer subjects were captured with portable devices. Automated analyses of muscle morphometry were performed using a custom-built deep-learning model (MyoVision-US), while manual analyses were performed by experts. Consistency between manual and automated analyses was determined using intraclass correlation coefficients (ICC), while predictability of MyoVision -US was calculated using adjusted linear regression (adj.R 2 ). Results: Manual analysis took approximately 24 hours to analyze all 180 images, while MyoVision - US took 247 seconds, saving roughly 99.8%. Consistency between the manual and automated analyses by ICC was good to excellent for all QC (ICC:0.85-0.99) and TA (ICC:0.93-0.99) measurements, even for critically ill (ICC:0.91-0.98) and lung cancer (ICC:0.85-0.99) images. The predictability of MyoVision-US was moderate to strong for QC (adj.R 2 :0.56-0.94) and TA parameters (adj.R 2 :0.81-0.97). Discussion: The application of AI automating lower limb muscle ultrasound analyses showed excellent consistency and strong predictability compared with human analysis. Future work needs to explore AI-powered models for the evaluation of other skeletal muscle groups.

A quantitative evaluation of the effect of meals on macular thickness in diabetic patients with diabetic macular edema.

PURPOSE: Central subfoveal thickness measurement is used in a large number of clinical trials to monitor the progression and treatment response of diabetic macular edema (DME) in patients of diabetic retinopathy (DR). Several studies have been carried out to investigate various factors affecting the central subfoveal thickness in order to minimize errors in the testing. We planned a study to investigate the effect of meals on central macular thickness (CMT) in patients with DME and compare that with nondiabetic patients. METHODS: In this observational study, 50 patients of diabetes with DME and 50 normal controls were included. Macular thickness was measured after overnight fasting and 2 h postprandial for both the groups. Any changes in morphology and CMT were evaluated. RESULTS: Each group had 22 females and 28 males with a mean age of 60.6 ± 6.6 in the diabetic group and of 49.66 ± 11.13 in the control group. Reduction in the CMT was noticed after the meals (mean: -9.78 ± 12.77 µm; P < 0.001) in those with DME as compared to the control group. This was more prominent in those who had intraretinal cystic spaces (17.14 ± 10.33 µm) and neurosensory detachment (66 µ). Patients with high blood sugar levels had higher CMT and a greater reduction in thickness was noticed in them postprandially (r = 0.414; P = 0.0028). CONCLUSION: The CMT values in patients with DME are significantly affected by meals. Hence, an attempt should be made to measure CMT during the fasting state for more accurate results.

Construct and criterion validity of muscle ultrasonography for assessment of skeletal muscle in patients recovering from COVID-19.

Background: The purpose was to investigate the content, construct, and criterion validity of muscle ultrasound in a mixed cohort of participants recovering from mild and critical COVID-19. Methods: A secondary analysis of a prospective cross-sectional study was conducted on data obtained from a battery of muscle and physical function assessments including a muscle biopsy and muscle ultrasonography (US). Rectus femoris (RF) muscle thickness (mT), quadricep complex (QC) mT, RF muscle cross-sectional area (CSA) using 2D freeform trace and estimated from Feret's diameter, and RF echo intensity (EI) were assessed with US. Muscle fiber CSA, fiber type, protein content in muscle fibers, extracellular matrix content (ECM; wheat-germ agglutin), and percent area of collagen in ECM (picrosirius red) were examined from vastus lateralis muscle biopsies. Spearman rho correlations (r) were performed to assess validity of ultrasound parameters. Results: Thirty-three individuals participated including 11 patients surviving critical COVID-19, 15 individuals recovering from mild-COVID, and 7 controls. There were several significant correlations between RF mT, QC mT, RF CSA, and RF EI with age, comorbid burden, body-mass index, and measures of muscle strength, muscle power, and physical function (range r = 0.35-0.83). RF Feret's CSA correlated to CSA of type II muscle fibers (r = 0.41, p = 0.022) and the average size of all muscle fibers (r = 0.39, p = 0.031). RF EI was correlated with collagen in muscle ECM (r = 0.53, p = 0.003) and protein content in muscle tissue (r = -0.52, p = 0.012). Conclusion: Muscle size and quality measured using US has moderate content and construct validity, and to lesser extent, fair to moderate criterion validity in a mixed cohort of individuals recovering from COVID. Muscle ultrasound quality (EI) appears to be sensitive at detecting muscle dysfunction as it is associated with strength, power, physical function, and collagen distribution in a mixed group of individuals recovering from COVID-19.

Upper Cervical Leiomyoma in an Adolescent Male.

Introduction: Leiomyomas are benign epithelial tumors with a female preponderance usually in the uterus, gastro-intestinal tract and skin. They are well-capsulated tumors with no mitotic activity and little pleomorphism. Primary leiomyoma in the upper cervical spine region is rare and the occurrence of these lesions in young immunocompetent males is extremely rare. Case Report: A 15-year-old male had swelling over the nape of the neck for 4 years with slight difficulty in neck movements for a few months. Asymptomatic 4 years back be developed a painless swelling at the nape of the neck on the right side initially the size of a pea which gradually increased size. A 10x8cm firm, on-tender and non-pulsatile swelling at the nape of the neck on the right extending from the occipital nuchal line and crossing the midline up to the posterior border of the sternomastoid. The skin over the swelling wasn't adherent and the swelling did not reduce on neck movements. Neck movements were terminally restricted with restriction on rotation towards the right. Routine X-ray's and magnetic resonance imaging were suggestive of a soft tissue mass in the inter-muscular plane on the posterior aspect more on the right side with a cystic component and causing thinning of the C2 lamina with no intraspinal extension. Biopsy was done. Findings were suggestive of a spindle cell benign tumor. Posterior en bloc excision was planned and the lesion blog with the entire capsule was excised and sent for histopathology which revealed the lesion was a leiomyoma. The patient has shown no clinical or radiological evidence of recurrence at 4 year fol-low-up. Conclusion: Leiomyomas in the upper cervical spine is extremely rare in adolescent immunocom-petent male.

Osteochondroma Presenting Clinically with Carpal Tunnel Syndrome in a 12-Year-old Boy.

INTRODUCTION: An exostosis is a benign growth of bone, which when capped with cartilage is called osteochondroma, which can appear as solitary or multiple, mostly affecting the long bones, pelvis, and shoulder region. The prevalence of known solitary exostosis is 1-2% in the general population. They are slow growing lesions with rare malignant transformation. In patients with a solitary exostosis, the chance of developing a chondrosarcoma out of an exostosis is around 1%. CASE REPORT: A 12-year-old boy presented to our outpatient department with complaints of pain, and swelling at the right wrist since 1 year and tingling numbness on and around palmar aspect of index and middle finger since 6 months. The swelling was of size 3 cm × 2 cm, Tinel's sign was positive. His blood parameters were normal. X-ray showed exostoses. Magnetic resonance imaging was suggestive of osteochondroma. Nerve conduction study was normal. Excision biopsy confirmed the diagnosis and also relieved all symptoms. CONCLUSION: Our case report is unique in its own way as it reminds us that when presented with a case of osteochondroma of the distal radius in children, carpal tunnel syndrome can also occur.

Innovative technique of mini-simple limbal epithelial transplantation in pediatric patients.

In this article, we introduce a modified technique of minor ipsilateral simple limbal epithelial transplantation (mini-SLET) in pediatric patients of limbal stem cell deficiency (LSCD). Two children with unilateral partial LSCD underwent the innovative technique of mini-SLET, where harvested limbal tissues were placed over the raw cornea and were covered with amniotic membrane. Both patients were followed till 9 months. Both cases showed favorable outcome and uneventful recovery. Results were comparable with the classical technique. This innovative modification of mini-SLET is safe, feasible, and an effective alternative with favorable visual outcome especially in pediatric population. It can be a breakthrough for LSCD management in developing countries with limited resources.

Anthropometric analysis of linear parameters of the Indian nose: A cross-sectional study and comparison with literature.

BACKGROUND: Many studies have been done to find out the accepted "ideal" appearance and proportions of the nose. However, much of this work has been limited to the facial architecture of the North American Caucasian population. Therefore, most beauty standards are driven by Western influences. AIMS AND OBJECTIVES: To measure different standard linear parameters of Indian faces and compare them with the studies found in the literature, in an endeavor to help in preoperative planning in rhinoplasty while maintaining their ethnicity. METHODS: This was a hospital-based cross-sectional study of 500 subjects. A total of 21 standard measurements were noted directly from the faces, and 11 proportional values calculated. Mean values with standard deviations were statistically used for comparisons with studies in the literature. RESULTS: There were significant differences between male and female subjects of our study in 16 variables. The proportional indices calculated also revealed significant differences statistically in 6 out of 11 measurements between male and female subjects. Significant differences were found in most of the parameters when our data were compared with Indian American, North American white population, Korean, Chinese, and African American. CONCLUSIONS: Facial measurements in the Indian population are different from those of other races, such as nasal index: (al-al × 100/n-sn), sn-prn x 100/ al-al index, and sn-prn x 100/n-Sn index, and it is important to have own set of parameters to act as standards guiding esthetic nasal surgeries while maintaining ethnicities. Our study is an attempt at the same. However, because of the huge diversity of the Indian population, it requires larger studies from different regions to achieve the final aim to create standards for cosmetic rhinoplasties.

Management of Post-DALK Recipient Posterior Stromal Scarring: A Novel Approach.

AIM: Management of recipient posterior stromal scarring following deep anterior lamellar keratoplasty (DALK) by a novel approach. METHODS: A side port knife bent at the tip is used to make a linear incision in the host posterior stroma. Plane between host posterior stroma and DALK tissue is separated using a reverse sinskey hook and multiple radial incisions are made using microvitroretinal scissors. The recipient posterior stromal wedges are removed using 20G vitrector with a cut rate of 800 cuts/min. A Descemet stripping endothelial keratoplasty lenticule is inserted into the anterior chamber and apposed to the posterior surface of DALK tissue using air tamponade. RESULT: This technique was used in 10 patients who showed clearing of the scarring after the surgery with good apposition of the donor graft to the previous DALK tissue. Conclusion: This is a sutureless, relatively simple, inexpensive, and effective novel surgical technique that avoids complications of open sky procedure and can be replicated in any ophthalmologic operation theatre setup.

Aggressive Vertebral Hemangioma Causing Recurring Myelopathy -A Rare Case Report and Review of Literature.

Introduction: Vertebral hemangiomas although benign vascular lesions few of these may be ag-gressive causing osseous, extra-osseous and/or epidural expansions with recurrence rate as low as 3%. It should be considered as one of the important differentials while dealing with lytic lesions in the dorsal spine causing compressive myelopathy. Case Report: A 16-year-old female came with an acute history of paraparesis with bladder in-volvement. She was diagnosed of vertebral hemangioma of D9 for which she underwent surgical decompression and fixation. At present, she had paraparesis with a sensory level of D10 on exami-nation. After radiological investigations (X-ray and MRI) she had high intensity signals in the extra osseous portion of D9 with significant neural compression indicating recurrence of vertebral he-mangioma. She underwent decompression with long segment instrumentation with prior arterial embolization. Histopathology features were suggestive of hemangioma and our diagnosis of recur-rence was confirmed. At 2 weeks, the patient had improved neurology with partial sensory recovery and Grade 2 power in the right lower limb and Grade 1 power in the left lower limb. Histopathology report confirmed the diagnosis of hemangioma indicating recurrence. At 6 months follow-up after aggressive rehabilitation, the patient was spastic and improved to Grade 3 power in the left lower limb and Grade 4 power in the right lower limb. The sphincteric control was also found to be fair at 1 year follow-up. Discussion: Vertebral hemangiomas when causing progressive neurological deficit warrant surgical decompression. The choice of intervention depends on location and extent of the tumor. Due to their high vascularity, it is advisable for to preoperatively carry out arterial embolization. Conclusion: Although commonly asymptomatic, vertebral hemangiomas may present as compressive myelopathy. Therefore, they should be detected early, intervened and followed up regularly to detect recurrence to prevent worsening of neurology and function.

New use of a pupillary expansion ring to avoid intraoperative positive vitreous pressure during triple procedures.

Positive vitreous pressure can complicate cataract surgery during a triple procedure by inadvertently extending the capsulorhexis. This occurs because the procedure is open sky and positive vitreous pressure cannot be countered by injecting ophthalmic viscosurgical devices. We describe a new use of a pupillary expansion ring (Malyugin) to achieve a stable open anterior chamber under open sky during triple procedures. The scrolls are tucked under cut margins of the host cornea to create the capsulorhexis, the cataractous nucleus is removed, and an intraocular lens (IOL) is implanted in the bag. This technique is especially useful in cases of hypermature cataract and nondilating pupils with positive vitreous pressure in patients having triple procedures. The technique provides a stable open anterior chamber, increasing to the safety of the procedure and the chance of achieving a continuous curvilinear capsulorhexis and IOL implantation in the capsular bag.

Leprosy Presenting with Iridocyclitis: A Diagnostic Dilemma.

PURPOSE: To report a case of lepromatous iridocyclitis that posed a diagnostic challenge. CASE REPORT: A 50-yeasr-old male developed profound loss of vision in the right eye, while he was in the hospital with septicemia presenting with fever, dysuria, and abdominal swelling. He also developed erythema nodosum on the legs. Skin incisional biopsy section, upon dermatology consultation, showed a granulomatous nodule in the dermis. The anterior chamber aspirate demonstrated lepra bacilli, which confirmed the diagnosis of lepromatous leprosy with type II reaction. The patient was treated with multidrug therapy and oral and topical steroids. CONCLUSION: This case highlights that the lepromatous iridocyclitis, a serious vision-threatening disorder requires a high index of suspicion for prompt diagnosis in atypical cases particularly in endemic areas. Examination of the aqueous humor can also be helpful in diagnosis.

Radial Artery Pseudoaneurysm in a Post-operative Case of Midshaft Radius Fracture.

INTRODUCTION: Pseudoaneurysms of arteries are not uncommon complications of vessel handling during surgery. Early identification and management is important to prevent disastrous complications such as rupture and thrombosis. CASE REPORT: We describe a case of a 28-year-old male who developed a pseudoaneurysm of the radial artery after being operated by plating for a mid-shaft radius fracture. He presented 2 weeks after surgery with swelling over the forearm which was confirmed to be a pseudoaneurysm after computed tomography angiography. It was treated with surgical excision and end-to-end anastomosis. CONCLUSION: A high index of suspicion must be maintained about the occurrence of this complication secondary to both trauma and surgery.

Surgical correction of persistent adult-onset cyclic strabismus.

A 24-year-old man developed cyclic esotropia following vitreoretinal surgery for retinal detachment in his right eye. He underwent right eye medial rectus recession (6 mm) and lateral rectus resection (8.5 mm) under local anesthesia for the correction of cyclic esotropia. Following surgery, he developed a unique pattern of cyclic strabismus that involved alternation between esotropia and exotropia every 24 hours. To treat this condition, the patient underwent lateral rectus recession (8.5 mm) and medial rectus posterior fixation of medial rectus in the right eye. Following surgery, he was corrected for heterotropia on both esotropic and exotropic days.

Giant Cell Tumor Presenting as A Spindle Shaped Tumor Arising From the Costovertebral Junction at D7, d8, d9 Levels.

INTRODUCTION: Giant cell tumor accounts for 5 to 9 percent of all primary bony tumors. Giant cell tumors are usually found in the long bones, most often the distal femur, proximal tibia, distal radius and rarely arising from the ribs. In this paper, we describe a case of giant cell tumor presented at an unusual location of the costovertebral junction as a dumbbell shaped tumor. CASE REPORT: Authors report a case of a 27 year old male patient with a giant cell tumor arising from the costovertebral junction at D7, D8, and D9 levels compressing the cord. Well-defined osteolysis with nonsclerotic borders were visualized on radiographs and CT scan images. Intermediate signal intensity on T1 sequences and central high signal and peripheral intermediate signal intensity on T2 sequences was visualized on MRI images. CT guided biopsy was reported as a moderately vascular lesion with spindle cell neoplasm suggestive of schwannoma. The cord was decompressed, tumor mass was surgically resected and stabilization with instrumentation was done. Histopatholgy was suggestive of giant cell tumor. CONCLUSION: Giant cell tumor may be included in the differential diagnosis in a well-defined lytic lesion when involving the costovertebral junction presenting as a spindle cell tumor on biopsy reports.

Recurrent GCT of Distal Femur Treated with Resection Arthrodesis with Non-Vascularized Bilateral Fibular Graft and A Custom-Made Interlock Nail.

INTRODUCTION: Giant Cell Tumors commonly occur around the knee joint in the age group of 20-30 years. They are treated with intra-lesional curettage or local resection and limb reconstruction. Management of large bone defects after resection is a challenge and is of ten complicated with non-union of grafts, infection and delayed weight bearing. CASE PRESENTATION: A 37-year-old male presented with an aggressive recurrent giant cell tumor of the distal femur. He was and was diagnosed with a GCT of the left distal femur 2 years ago for which he was treated with an intralesional curettage and Poly methylmetacrylate implantation. A resection arthrodesis using a bilateral non-vascularised intramedullary fibular graft and a custom made intramedullary nail was performed. The follow-up radiographs showed union at graft-host junction and hypertrophy of the grafted fibula at 2 years post surgery. CONCLUSION: Non-vascularised fibular graft is an effective alternative for resection arthrodesis with the advantages of a simpler and shorter surgical procedure and without the needs for a microsurgical setup.

Inducible nerve growth factor delivery for peripheral nerve regeneration in vivo.

BACKGROUND: HEK-293 cells can be genetically modified to release and regulate nerve growth factor (NGF) in vitro. The aim of this study was to evaluate the impact of this NGF delivery system on peripheral nerve regeneration in vivo. METHODS: HEK-293 cells were transfected with an ecdysone receptor, NGF cDNA, and herpes simplex virus-thymidine kinase suicide vector. NGF production is induced by ponasterone A and stopped by ganciclovir. A 13-mm sciatic nerve gap was bridged with Silastic conduits in 120 nude rats, and transfected HEK-293 cells were added, induced, and boostered to secrete bioactive NGF. RESULTS: The induction of the cell line and additional booster with ponasterone A demonstrated significantly higher levels of bioactive NGF, enhanced macroscopic nerve growth, improved functional recovery, and histologic regeneration when compared with control groups after 7, 14, and 21 days, and 2 and 4 months. The treatment with ganciclovir resulted in suppression of the NGF production and decreased functional and histologic outcomes. CONCLUSIONS: Transfected HEK-293 cells can be regulated to inducibly produce bioactive NGF in vivo over prolonged periods. This tissue-engineered nerve construct including the NGF delivery system is able to improve peripheral nerve regeneration and functional recovery and appears to be superior to nerve isografts.

Traumatic extradural hematoma - role of non-surgical management and reasons for conversion.

BACKGROUND: To study the role of conservative management and various reasons for conversion to surgical intervention in traumatic extradural hematoma (EDH). SETTING: Government Medical College Jammu. MATERIALS AND METHODS: One hundred-twenty trauma patients diagnosed as extradural hematoma on CT scan were managed during 1 year period. OUTCOMES: Role of conservative management and various reasons for conversion to surgical intervention were studied. RESULTS: Out of these 120 patients admitted 67 were managed conservatively, 53 cases were operated upon. 31 were operated upon immediately and 22 were operated upon as delayed. There was 1 death and 4 had poor outcome in this group of patients. CONCLUSION: It is stressed that small size <10 ml, GCS >12 and locations other than temporal area are the criteria for conservative management. Twenty-two patients out of 89 were needed to be treated surgically during the course of conservative management due to neurodeterioration, increase in size of hematoma on CT, bradycardia, hemiparesis, pupillary abnormalities, delay in referral and only 18% had poor outcome. A strict vigilance is to be kept for clinical deterioration and various reasons mentioned above are to be kept in mind and patients should be subjected to repeated CT scan. Early diagnosis and immediate surgical intervention had good outcome, which shows the fruitful results of early diagnosis and intervention.

Correlation of rapid phenotypic changes and insulin production of differentiated human adipose tissue-derived stem cells.

The study investigates adipose tissue-derived stem cells (ADSCs) to differentiate into insulin-secreting cells in vitro. ADSCs were exposed to differentiation medium or control medium. Culture medium was harvested for quantification of insulin and cells were classified into stages of differentiation ranging from normal appearance to islet-like clusters. Morphologic analysis demonstrated marked phenotypic changes towards the islet cell lineage. Thirty-six percent of cells exposed to differentiation medium had progressed to morphologic end-stage after 15 days. Chemiluminescence of the culture medium determined that insulin secretion by differentiated cells progressively increased, reaching a maximum at day 7. Insulin secretion by control cells was significantly less at all time points. A high correlation of secreted insulin and the presence of stage 3 cells were observed throughout the entire experiment. ADSCs can be differentiated into insulin-secreting cells in response to defined culture conditions. The secreted insulin significantly correlates with phenotypic changes throughout the differentiation process.

Release kinetics of polymer-bound bone morphogenetic protein-2 and its effects on the osteogenic expression of MC3T3-E1 osteoprecursor cells.

BACKGROUND: In an effort to augment scaffold performance, additives such as growth factors are under investigation for their ability to optimize the "osteopotential" of synthetic polymer scaffolds. In parallel research, bone morphogenetic protein-2 (BMP-2), a growth factor that initiates bone formation, has been locally delivered to augment fracture healing and spinal fusion. The authors hypothesize that BMP-2 can be covalently bound to a polymer substrate, increasing its concentration and bioavailability over longer periods, thus improving the efficacy of the growth factor and subsequently the bony matrix production. It would remain bound longer when compared with published controls. This prolonged binding would then increase the bioavailability of the growth factor and thus increase bony matrix production over a longer interval. METHODS: Mouse preosteoblast MC3T3-E1 cells were cultured on poly(lactic-co-glycolic acid) and polycaprolactone polymer disks covalently bound with BMP-2 to assess the progression and quality of osteogenesis. Covalent binding of BMP-2 to each polymer was visualized by immunohistochemical analysis of polymer-coated microscope slides. The quantity of covalently bound BMP-2 was determined using enzyme-linked immunosorbent assay. RESULTS: Polymerase chain reaction results showed elevated expression levels for alkaline phosphatase and osteocalcin genes. BMP-2 was released from polycaprolactone over 2 weeks, with 86 percent remaining covalently bound, in contrast to 93 percent retained by poly(lactic-co-glycolic acid). CONCLUSIONS: BMP-2, proven to alter polymer osteogenicity, remained bound to poly(lactic-co-glycolic acid), which may render poly(lactic-co-glycolic acid) an ideal choice as a polymer for scaffold-based bone tissue engineering using growth factor delivery.

Long-term maintenance of neuronally differentiated human adipose tissue-derived stem cells.

Recent studies reporting differentiation of early neural progenitors of human adipose tissue-derived stromal cells (ADSCs) has aroused interest among investigators for regenerative medicine. The aim of this study was to investigate the differentiation of ADSCs to neuron-like cells and to extend the life span of these differentiated ADSCs in vitro using our new DE-1 medium. After primary culture and expansion, ADSCs were incubated in a new long-term neuronal induction medium that maintains ADSCs in a differentiated state for 8 weeks. Neuronal differentiation was identified using immunocytochemistry, reverse-transcriptase polymerase chain reaction, and Western blotting. We found that the optimal differentiation protocol induced the ADSCs to express early neuronal markers, including nestin and neuronal nuclear antigen (NeuN), as well as the mature astrocyte marker glial fibrillary acidic protein (GFAP). Neuronal morphological characteristics were recognized in approximately 40% to 50% of the cell populations maintained over 8 weeks, and 60% to 80% of the differentiated cells expressed neuronal specific markers, including nestin, GFAP, NeuN, Trk-A, vimentin, and neuron-specific enolase. The data show that our DE-1 medium is capable of achieving a greater number of differentiated ADSCs for a longer period of time. This result bodes well for the application of ADSCs in in vivo peripheral nerve regeneration.