Ultrasound-guided injection and aspiration of small joints: techniques, pearls, and pitfalls.

Ultrasound (US)-guided musculoskeletal intervention of small joints or joints other than the shoulder, elbow, hip, knee, and ankle can be technically challenging. Small joints produce a narrower landing zone for the needle and a smaller target that may be made even more inaccessible by bulky osteophytes. Sonographic (US) guidance offers important advantages including near-field visualization of the joint and soft tissues, ease of access, portability, ability to compare with the contralateral side, and lack of ionization radiation. This review article focuses on the performance of US-guided injections and aspirations involving small joints (joint capacity < 2 mL and/or typically evaluated or injected with a compact linear transducer). For each joint (temporomandibular, acromioclavicular, sternoclavicular, distal radioulnar, symphysis pubis, and joints of the digits of the hands and feet), a brief overview of the relevant anatomy, indications, procedural description, pearls and pitfalls will be highlighted. This article demonstrates the various approaches to diagnostic or therapeutic injection and aspiration of small joints with the aid of US images, cines and graphic illustrations, emphasizing joint positioning, anatomic landmarks, and needle trajectory for a safe and efficacious procedure. A brief review of available literature for each joint will also be provided.

A Review of Materials and Medications with Religious or Dietary Significance in the Interventional Radiology Suite.

A holistic approach to patient-centered care should include cultural and religious considerations. Certain cultural groups have beliefs that may restrict the use of particular animal-derived products and chemicals. A working knowledge of ingredients commonly used in the interventional suite with religious and cultural connotations may be helpful. This review article highlights medications and medical devices with cultural or religiously sensitive ingredients used in interventional radiology departments and provides a framework for addressing this common scenario.

CT-guided scapulothoracic bursal injection-technical considerations in planning needle trajectory and confirming bursal distribution.

OBJECTIVE: To describe a technique of targeted CT-guided scapulothoracic bursal injections in an illustrated and step-wise manner. MATERIALS AND METHODS: This technical report describes the authors' experience in using CT guidance for targeted scapulothoracic bursal injections in 8 patients with suspected scapulothoracic bursitis over an 18-month period. RESULTS: The outcome of the image-guided injection was retrospectively assessed in 8 patients. None of the patients had any complications related to the procedure. Symptomatic improvement was achieved in 62.5% of the patients while 25% of patients did not report any benefit from the injection. CONCLUSION: In providing a record of needle tip position and contrast distribution, CT-guided scapulothoracic bursal injections provide an objective record of the procedure, which may assist in further treatment planning.

An Insight into Multisystem Inflammatory Syndrome in Adults Associated with Recent SARS-COV-2 Infection: A Case Series.

IMPORTANCE: Multisystem inflammatory syndrome-adults (MIS-A) occur in the postacute coronavirus disease 2019 (COVID-19) period with a diverse clinical presentation. A high index of suspicion, early recognition, diagnosis, and treatment of MIS-A might alleviate COVID-19-related morbidity and mortality. OBJECTIVE: To report seven cases of MIS-A with evidence of recent COVID-19 infection. This is a case series-based study and presents bona fide experiences in terms of main findings and treatment options. MATERIALS AND METHODS: It is a retrospective observational study. We retrospectively collected data on all patients who were diagnosed and treated for MIS-A during the period after the second wave of COVID-19 in India, that is, from June 2021 to November 2021and who were hospitalized in the author's unit. All patients fulfilled the morbidity and mortality weekly report (MMWR) criteria for multisystem inflammatory syndrome in adults. The presenting symptoms, clinical and laboratory parameters, management, and outcome of these seen cases are discussed in this case series-based review.. RESULTS: Data from seven patients were analyzed. Six of them were male, and one patient was female. The median age was 65 years. Four patients had a history of vaccination for COVID-19, three had a history of COVID-19 symptomatic infection in the past, and one patient had contact with COVID-19 in the previous 12 weeks. None of them tested positive for COVID-19 real-time reverse transcription polymerase chain reaction (RT-PCR) test, and all had positive COVID-19 serology. The commonest extrapulmonary organ involved were the cardiovascular and renal systems, followed by the gastrointestinal and central nervous systems (CNS). All had evidence of hyperinflammation. Intravenous immunoglobulin (IVIg) was used in four patients, and steroids were used in all seven patients. The median length of stay (LOS) was 11 days. One patient succumbed to multiorgan failure. CONCLUSIONS: Multisystem inflammatory syndrome (MIS) can affect children (MIS-C) as well as adults (MIS-A). MIS-A is a serious, life-threatening, hyperinflammatory febrile syndrome associated with recent COVID-19 infection and involves multiple organs like the heart, lungs, kidneys, brain, gastrointestinal organs, skin, eyes etc. Clinical suspicion and testing for evidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are needed to identify and treat adults suspected to have MIS-A. This case series demonstrates that even the elderly population can be affected and that administration of IVIg and steroids are effective options in management in addition to the usual "standard of care" treatment. Early recognition and prompt treatment of MIS-A could improve clinical outcomes and reduce the mortality rate.

Anti-HSV-2 activity of Terminalia chebula Retz extract and its constituents, chebulagic and chebulinic acids.

BACKGROUND: Development of new and effective therapeutics for sexually transmitted herpes simplex virus-2 (HSV-2) infection is important from public health perspective. With an aim to identify natural products from medicinal plants, in the present study, the potential of Terminalia chebula Retz was investigated for its activity against HSV-2. METHODS: Fruits of Terminalia chebula Retz were used to prepare 50% ethanolic extract. In addition, chebulagic acid and chebulinic acid both purified from T. chebula were also used. The extract as well as purified compounds were first used to determine their in vitro cytotoxicity on Vero cells by MTT assay. T. chebula extract, chebulagic acid, chebulinic acid along with acyclovir were subsequently assessed for direct anti-viral activity, and their ability to inhibit attachment and penetration of HSV-2 to the Vero cells. In addition, their anti-HSV-2 activity was also determined by in vitro post-infection plaque reduction assay. RESULTS: Cytotoxicity assay using Vero cells revealed CC50 = 409.71 ± 47.70 µg/ml for the extract whereas chebulagic acid and chebulinic acid showed more than 95% cell viability up to 200 µg/ml. The extract from T. chebula (IC50 = 0.01 ± 0.0002 µg/ml), chebulagic (IC50 = 1.41 ± 0.51 µg/ml) and chebulinic acids (IC50 = 0.06 ± 0.002 µg/ml) showed dose dependent potent in vitro direct anti-viral activity against HSV-2. These also effectively prevented the attachment as well as penetration of the HSV-2 to Vero cells. In comparison, acyclovir showed poor direct anti-viral activity and failed to significantly (p > 0.05) prevent the attachment as well as penetration of HSV-2 to Vero cells when tested upto 50 µg/ml. However, in post-infection plaque reduction assay, T. chebula extract, chebulagic and chebulinic acids showed IC50 values of 50.06 ± 6.12, 31.84 ± 2.64, and 8.69 ± 2.09 µg/ml, respectively, which were much lower than acyclovir (71.80 ± 19.95 ng/ml). CONCLUSIONS: The results presented herein suggest that T. chebula extract, chebulagic and chebulinic acids have higher direct antiviral activity against HSV-2 and efficacy to inhibit virus attachment and penetration to the host cells as compared to acyclovir. However, acyclovir is more potent to inhibit post-infection virus replication. Hence, T. chebula may be a useful candidate for developing alternative therapy for prevention of sexually transmitted HSV-2 infection. ᅟ.

Congenital Perisylvian Syndrome presenting as Post-partum Seizures with Preeclampsia.

Whether preceded by preeclampsia, or occuring without antecedent warning symptoms, eclamptic seizures usually occur in the antepartum period between 20 and 40 weeks of gestation or within a few hours to 2 days postpartum. We report the case of a patient with pre-eclampsia who developed seizures after more than 2 days of delivery. In view of late onset postpartum seizures and non-responsiveness to magnesium sulphate, she was further evaluated and diagnosed to have congenital perisylvian syndrome(CPS). In CPS, polymicrogyric cortex is distributed in variable extensions around the sylvian fissure i.e. a structural malformation of the brain with underlying anomaly of polymicrogyria.

Infection Associated Secondary Hemophagocytic Lymphohistiocytosis in Sepsis Syndromes - A Tip of an Iceberg.

BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is a rare, underdiagnosed, fatal and devastating hyperinflammatory syndrome that has gained increasing recognition over the past decade. Patients with HLH present with clinical and laboratory evidence of uncontrolled inflammation. Delay in diagnosis and management inevitably leads to a rapidly progressive and fatal course. In this case series, we present 7 cases of secondary HLH (sHLH) in adults with their presentation, course, and outcomes. MATERIAL AND METHODS: We retrospectively looked at the 7 cases of secondary HLH who were diagnosed and managed in our institute between January 2013 and august 2015. Medical records were retrieved from medical records department and data analyzed and tabulated. The median age at diagnosis was 35 years (age range 26-72 years). Diagnosis was based on HLH 2004 diagnostic criteria. RESULTS: We report profile of 7 adult patients with sHLH. All patients had a short history of illness (<2 weeks) and presented uniformly with prolonged fever, bi or trilineage cytopenia and multiorgan dysfunction syndrome (MODS) at admission or developed MODS during the course of their illness. None of them had prediagnosed HLH. All patients fulfilled 5 to 6 of 8 criteria as per HLH 2014 diagnostic criteria. The median length of hospital stay was 12 days (range 7-50 days) and the median time to diagnosis was 5 days (range 3 to 21 days). Mortality was 57%. CONCLUSIONS: HLH is a rare and under-diagnosed clinical syndrome and is rapidly fatal if not diagnosed and managed timely. The cases reported in literature probably represent a tip of an iceberg of large number of undiagnosed cases mostly labeled as sepsis with MODS in critical care units. sHLH should be suspected in any patient who present with persistent and prolonged fever, transaminitis, cytopenia, and high serum Ferritin or dramatically rising serial serum Ferritin. Early diagnosis and prompt aggressive treatment are vital for patients' survival and favorable outcome.

Pericardial Effusion with Cardiac Tamponade as a form of presentation of Primary Hypothyroidism.

Hypothyroidism is a rare cause of pericardial effusion (PE). Pericardial effusion secondary to hypothyroidism remains a diagnostic challenge for clinicians because of its inconsistency between symptoms and amount of pericardial effusion. We report an atypical case that presented with ascites and was diagnosed to have cardiac tamponade secondary to primary hypothyroidism. Besides repeated pericardiocentesis she eventually required surgical management and optimization of medical therapy to manage the massive pericardial effusion.

Dorsal Wrist Carpal Boss Impingement-Dynamic Ultrasound to the Rescue!

The "carpal boss" is a variant present in 19% of the population according to cadaveric studies but becomes symptomatic in only 1% of cases. With the rising popularity of "yoga," which includes prolonged hyperextension at the wrist joint with weight bearing, an increasing number of individuals with silent carpal boss present with dorsal wrist pain due to impingement over the dorsal soft tissues by this innocuous bony protuberance. This warrants the attention of radiologists and clinicians while dealing with wrist pain. It can be challenging to identify this bossing on routine radiographs, necessitating special views. We describe the use of dynamic ultrasound in diagnosing "symptomatic" carpal boss, the effects of which become even more evident on imaging during hyperextension-the triggering movement.

It Is Not Only the Meniscus That Flips-A Case of TFCC Tear with a Flipped Fragment in the Distal Radioulnar Joint.

Acute wrist injuries with ongoing ulnar-sided wrist pain warrant a magnetic resonance imaging (MRI) to diagnose ligamentous injuries. Triangular fibrocartilage complex (TFCC) tears have been classified and described in the literature but complex tear patterns have limited representation. Bucket-handle tears of the TFCC represent only 0.5% of TFCC tears and have recently been identified, posing a diagnostic and management challenge. Preoperative diagnosis is possible with MRI and necessary for optimal and early surgical management. The authors describe a unique case of a flipped tear of the central disc of the TFCC, where the fragment was flipped into the distal radioulnar joint, a site hidden during routine arthroscopy.

Ultrasound-guided cutaneous nerve chemo-ablation for severe access site neuropathic pain-A case report.

Neuropathic pain at the cannulation site is challenging, both for the patient and the dialysis team. We present a case of a middle-aged man on chronic hemodialysis, who developed excruciating pain at the cannulation area without incident, limiting his dialysis sessions. Multidisciplinary collaboration allowed identification of the cutaneous nerve-the inferior lateral cutaneous nerve of the arm, relaying his pain. Subsequent ultrasound-guided phenol chemoablation resulted in the complete resolution of his pain and allowed continued use of the well-functioning fistula for dialysis.

Carbon nanosheets to unravel the production of bioactive compounds from microalgae: A robust approach in drug discovery.

The conglomeration of active pharmaceutical ingredients (APIs) has influenced the development of life-saving drugs. These APIs are customarily synthetic products, albeit with adverse side effects. Thus, to overcome the bottlenecks associated with synthetically derived APIs, the approach of photocatalytically obtaining bioactive compounds from natural ingredients has emerged. Amid the pool of photoactive nanomaterials, this short review emphasizes the intelligent strategy of exploiting photoactive carbon nanosheets to photocatalytically derive bioactive compounds from natural algal biomass to treat many acute or chronic medical conditions. Carbon nanosheets result in phototrophic harvesting of bioactive compounds from microalgae as a result of their being an effective biocatalyst that increases the rate of photosynthesis. To understand the clinical translation of bioactive compounds, the pharmacodynamics of algal bioactive compounds are highlighted to determine the practicality and feasibility of using this green approach for pharmaceutical drug discovery.

Molar Tooth in the Knee - A Case of Simultaneous Medial and Lateral Bucket Handle Tear with Arthroscopic Correlation and a Review of Literature.

Introduction: Simultaneous bucket handle tear of both lateral and medial menisci is a rarely encountered entity. MR imaging helps in pre-operative diagnosis for optimal operative planning. However, as this condition is not seen in routine practice, awareness of various imaging signs is essential to identify this condition. Few signs on coronal and sagittal images have been described in the literature but none so far on axial images. Case Presentation: We propose a novel "molar tooth sign" in the knee on axial MRI images, in which we identified in the case of a young male with recurrent knee locking after a fall from height. Conclusion: Different modes of injury can lead to different patterns of meniscal and ligament tears. Having an allied sign which is, furthermore, easy to imagine will help, not only the radiologists but also the surgeons, to identify rare types of meniscal tears similar to the index case.

Bony Cyst in a Ground Glass Matrix: A Rare Case Report of Craniofacial Fibrous Dysplasia with Secondary Aneurysmal Bone Cyst.

Fibrous dysplasia has various ways of presentation including syndromic associations and secondary changes within the lesion. We present a case of a 21-year-old female with craniofacial fibrous dysplasia, presenting with proptosis and intermittent blurring of vision due to focal fibrous dysplasia involving the frontal bone with secondary aneurysmal bone formation that was provisionally diagnosed on imaging and confirmed on histopathology. This case demonstrates the typical imaging findings of fibrous dysplasia with seldom encountered secondary aneurysmal bone cyst formation and also discusses about the pathology and management of the craniofacial fibrous dysplasia.

Exploring the Role of Carbon-Based Nanomaterials in Microalgae for the Sustainable Production of Bioactive Compounds and Beyond.

An enchanting yet challenging task is the development of higher productivity in plants to meet the ample food demands for the growing global population while harmonizing the ecosystem using front-line technologies. This has kindled the practice of green microalgae cultivation as a driver of key biostimulant products, targeting agronomic needs. To this end, a prodigious and economical strategy for producing bioactive compounds (sources of secondary metabolites) from microalgae using carbon-based nanomaterials (CNMs) as a platform can circumvent these hurdles. Recently, the nanobionics approach of incorporating CNMs with living systems has emerged as a promising technique to develop organelles with new and augmented functions. Herein, we discuss the importance of 2D carbon nanosheets (CNS) as an alternative carbon source for the phototrophic cultivation of microalgae. CNS not only aids in cost reduction for algal cultivation but also confers combinatorial innate or exogenous functions that enhance its programmed biosynthetic metabolism, proliferation, or tolerance to stress. Moreover, the inherent ability of CNS to act as efficient biocatalysts can enhance the rate of photosynthesis. The primary focus of this mini-review is the development of an economic route for enhanced yield of bioactive compounds while simultaneously serving as a heterogeneous platform for enhancing the sustainable production of biostimulants including bioactive compounds from algal biomass for pharmaceutical and nutraceutical applications.

An Unusual Presentation of a Completely Transected Aorta Presenting As Acute Limb Ischemia With Intramural Thrombus.

Contrast-enhanced multidetector computed tomography is currently the preferred imaging modality to diagnose acute traumatic aortic injury (ATAI). Rarely, ATAI can present with atypical findings that make the diagnosis and further management exceptionally challenging. Furthermore, ATAI can also be associated with inferior vena cava injury showing only indirect signs on later imaging. We present an unusual case of traumatic aortic disruption mimicking acute limb ischemia.

Graphene quantum dot-porphyrin/phthalocyanine multifunctional hybrid systems: from interfacial dialogue to application.

Engineered well-ordered hybrid nanomaterials are symbolically at a pivotal point, just ahead of the long-anticipated transformation of the human race. Incorporating newer carbon nanomaterials like graphene quantum dots (GQDs) with tetrapyrrolic porphyrins (Pp) and phthalocyanines (Pc) is crucial for achieving exquisite molecular nanoarchitectures that are superior to their individual components. The outcomes of this, particularly in the case of graphene quantum dot-porphyrin/phthalocyanine (GQD-Pp/Pc) hybrids, remain comprehensively unexplored to date. Interestingly, GQD-Pp/Pc hybrids provide a modern strategy to regulate matter by utilising intramolecular and organisational properties to create well-defined nanocomposites via a synergistic enhancement effect. The high molar absorption coefficient and enhanced energy transfer, hole and electron transfer abilities capabilities allow Pp and Pc to exhibit a wide spectrum of photophysical and photochemical features. However, their low biostability, non-specific tumor-targeting properties, hydrophobicity, and low cellular internalisation efficiency limit their extensive biomedical utility. Conjugating Pp/Pc to nanocarriers such as GQDs improves their targeted delivery, immunological tolerance, and longevity. Due to the zero-order release kinetics of GQDs, they can assist in maintaining a steady rate of photosensitiser (PS) delivery at the desired site. To completely rationalise the functionalization of GQD-Pp/Pc species at interfaces, we investigate the current prominence and future potential of porphyrin-related graphene nanosystems, especially GQDs, for the development of various applications. This encouraging report demonstrates how GQD-Pp/Pc species can be used to examine new phenomena at the multidisciplinary level. Notably, a customised hybrid system optimises amendable and diverse functional properties, yielding a ray of hope in the fields of photodynamic therapy (PDT), photocatalysis, solar cells, sensing, and beyond via various photo-physicochemical approaches such as electron transfer, catalytic transformation, light-harvesting, and axial/peripheral ligation of adducts. Gratifyingly, the covalent and non-covalent coupling of functional molecular units at interfaces enable new properties to be generated in hybrid systems.