Hydraulic modeling of the Periyar River using HEC-RAS: unraveling flow dynamics.

The Periyar River, a vital component of Kerala's ecosystem in India, serves as a lifeline supporting agriculture, hydropower generation, and ecological equilibrium. This study adopts a multifaceted approach to address critical challenges in the Periyar basin, with a primary focus on flood mitigation due to the region's susceptibility to devastating floods. Covering a length of 67.85 km, the study intricately segments the Periyar River into distinct reaches for a comprehensive steady flow analysis, considering factors such as seasonal monsoon fluctuations, diverse catchment topography, and human-induced alterations. Utilizing advanced modeling techniques, particularly HEC-RAS software, the study effectively predicts and simulates shifts in hydraulic behavior. The results, including velocity plots and cross-sectional maps, offer accurate insights into critical parameters, enabling the identification of areas with high velocity occurrence. This information proves instrumental in making informed decisions for the construction of river restoration structures, crucial for mitigating the impact of floods. The study's findings contribute valuable tools for future forecasting and sustainable management of the Periyar River, addressing the complex interplay of natural and anthropogenic factors.

G6 continuous glucose monitoring system feature use and its associations with glycaemia in Europe.

AIMS: Current continuous glucose monitoring (CGM) devices provide features that alert individuals with diabetes about their current and impending adverse glycaemic events. The use of these features has been associated with glycaemic improvements. However, how these features are utilised under real-world conditions has not been well studied. We queried a large database to quantify utilisation of the Dexcom G6 system features and how utilisation impacted glycaemic outcomes within a cohort of European users. METHODS: This 6-month retrospective, observational, large database analysis utilised anonymised data from a sample of 47,784 Europe-based G6 users. Primary outcome measures were associations between utilisation and customisation of High/Low threshold alerts, 'urgent low soon' (ULS) alert, and established CGM metrics. RESULTS: Users in the Germany, Austria, Switzerland region (n = 20,257), the Nordic countries (n = 10,314), United Kingdom (n = 9006), Italy (n = 4747), France (n = 2130) and Spain (1330) were included. All alert features were utilised by >75% of the cohort across all regions/countries and age groups. Enabling the Low alert and ULS alert was associated with lower percentage of time below range compared to disabling the Low alert (p < 0.001). Enabling the High alert was associated with higher percentage of time in range (%TIR) and lower percentage of time above range (%TAR) %TAR compared to disabling the High alert (p < 0.001). Paediatric patients and older adults tended to set a higher threshold for High/Low alerts, while younger adults tended to use lower threshold values for High/Low alerts. CONCLUSIONS: Individuals who utilised the Dexcom G6 features showed better glycaemic control, particularly among those who utilised more sensitive High alert and Low alert settings, than users who did not utilise the system features.

Foamy Virus Vector Carries a Strong Insulator in Its Long Terminal Repeat Which Reduces Its Genotoxic Potential.

Strong viral enhancers in gammaretrovirus vectors have caused cellular proto-oncogene activation and leukemia, necessitating the use of cellular promoters in "enhancerless" self-inactivating integrating vectors. However, cellular promoters result in relatively low transgene expression, often leading to inadequate disease phenotype correction. Vectors derived from foamy virus, a nonpathogenic retrovirus, show higher preference for nongenic integrations than gammaretroviruses/lentiviruses and preferential integration near transcriptional start sites, like gammaretroviruses. We found that strong viral enhancers/promoters placed in foamy viral vectors caused extremely low immortalization of primary mouse hematopoietic stem/progenitor cells compared to analogous gammaretrovirus/lentivirus vectors carrying the same enhancers/promoters, an effect not explained solely by foamy virus' modest insertional site preference for nongenic regions compared to gammaretrovirus/lentivirus vectors. Using CRISPR/Cas9-mediated targeted insertion of analogous proviral sequences into the LMO2 gene and then measuring LMO2 expression, we demonstrate a sequence-specific effect of foamy virus, independent of insertional bias, contributing to reduced genotoxicity. We show that this effect is mediated by a 36-bp insulator located in the foamy virus long terminal repeat (LTR) that has high-affinity binding to the CCCTC-binding factor. Using our LMO2 activation assay, LMO2 expression was significantly increased when this insulator was removed from foamy virus and significantly reduced when the insulator was inserted into the lentiviral LTR. Our results elucidate a mechanism underlying the low genotoxicity of foamy virus, identify a novel insulator, and support the use of foamy virus as a vector for gene therapy, especially when strong enhancers/promoters are required.IMPORTANCE Understanding the genotoxic potential of viral vectors is important in designing safe and efficacious vectors for gene therapy. Self-inactivating vectors devoid of viral long-terminal-repeat enhancers have proven safe; however, transgene expression from cellular promoters is often insufficient for full phenotypic correction. Foamy virus is an attractive vector for gene therapy. We found foamy virus vectors to be remarkably less genotoxic, well below what was expected from their integration site preferences. We demonstrate that the foamy virus long terminal repeats contain an insulator element that binds CCCTC-binding factor and reduces its insertional genotoxicity. Our study elucidates a mechanism behind the low genotoxic potential of foamy virus, identifies a unique insulator, and supports the use of foamy virus as a vector for gene therapy.

Knowledge Discovery and Data Mining: Implications for Nurse Leaders.

As systems evolve, their tendency is to become more complex. Studies in the field of complex systems have generated new perspectives on the application of management strategies in health systems. This is the 2nd in a series of articles addressing the mounting challenges faced by nursing leaders demanding insights from the vast amounts of information collected and stored by their organizations.

Glycemic Outcomes and Feature Set Engagement Among Real-Time Continuous Glucose Monitoring Users With Type 1 or Non-Insulin-Treated Type 2 Diabetes: Retrospective Analysis of Real-World Data.

BACKGROUND: The benefits of real-time continuous glucose monitoring (RT-CGM) are well established for patients with type 1 diabetes (T1D) and patients with insulin-treated type 2 diabetes (T2D). However, the usage and effectiveness of RT-CGM in the context of non-insulin-treated T2D has not been well studied. OBJECTIVE: We aimed to assess glycemic metrics and rates of RT-CGM feature utilization in users with T1D and non-insulin-treated T2D. METHODS: We retrospectively analyzed data from 33,685 US-based users of an RT-CGM system (Dexcom G6; Dexcom, Inc) who self-identified as having either T1D (n=26,706) or T2D and not using insulin (n=6979). Data included glucose concentrations, alarm settings, feature usage, and event logs. RESULTS: The T1D cohort had lower proportions of glucose values in the 70 mg/dl to 180 mg/dl range than the T2D cohort (52.1% vs 70.8%, respectively), with more values indicating hypoglycemia or hyperglycemia and higher glycemic variability. Discretionary alarms were enabled by a large majority in both cohorts. The data sharing feature was used by 38.7% (10,327/26,706) of those with T1D and 10.4% (727/6979) of those with T2D, and the mean number of followers was higher in the T1D cohort. Large proportions of patients with T1D or T2D enabled and customized their glucose alerts. Retrospective analysis features were used by the majority in both cohorts (T1D: 15,783/26,706, 59.1%; T2D: 3751/6979, 53.8%). CONCLUSIONS: Similar to patients with T1D, patients with non-insulin-treated T2D used RT-CGM system features, suggesting beneficial, routine engagement with data by patients and others involved in their care. Motivated patients with diabetes could benefit from RT-CGM coverage.

Psychosis After Infection With SARS-CoV-2 in an Adolescent: A Case Report.

As many as one-third of patients who have coronavirus disease 2019 (COVID-19) develop long-term neuropsychiatric symptoms, such as anxiety, depression, brain fog, psychosis, seizures, and suicidal behavior.1 Several case reports have demonstrated the association between psychotic symptoms following infection with COVID-19 in adults.1,2 In a first episode of psychosis, clinical findings on history, examination, and diagnostic studies may suggest that the psychotic symptoms are due to medical illness, which may be reversible. The presentation can include acute onset, predominance of visual or tactile hallucinations, and association with other neurological symptoms.3.

A rare case of sino-nasal aneurysmal bone cyst.

Aneurysmal bone cysts (ABC) are rare in the paranasal sinuses. They are benign expansile multicystic masses containing blood-filled spaces which typically occur in the long bones of pediatric patients. The lesion often produces symptoms due to the compression of adjacent structures or pathological fracture and depends on localization. In this case report, we discuss a 28-year-old female who presented with left-sided headache, left eye proptosis, and diplopia. Radiologic evaluation revealed a left paranasal sinus expansile multicystic mass with internal blood fluid levels displacing and thinning the left medial orbital wall which suggested the diagnosis of ABC. Radiologists should be familiar with and comfortable diagnosing ABC in the head and neck, and be able to differentiate this entity from others, such as telangiectatic osteosarcoma. Biopsy can be challenging since blood products may be the only material identified and may produce tissue that is difficult to interpret or misdiagnosed.

Continuous Glucose Monitoring: An Opportunity for Population-Based Diabetes Management.

The increasing prevalence of prediabetes and diabetes in the United States poses a serious threat to the health of the population. Closely associated with obesity, hypertension, dyslipidemia, and cardiovascular disease, a diagnosis of diabetes or prediabetes carries with it life-altering demands. Critically important among these is the requirement for frequent glucose level checks-typically performed with blood obtained from a fingerstick. Innovative real-time continuous glucose monitoring (rtCGM) technology makes it possible for patients and their clinicians to receive continuous glucose level measurements around the clock without finger sticks. Accruing evidence shows that rtCGM is an effective tool for patients and their clinicians in managing diabetes (ie, maintaining glucose levels within the recommended target range) and in understanding how lifestyle behaviors directly influence glucose levels. In recent years, a number of large payer organizations (eg, private health insurers, employers) have incorporated rtCGM in their diabetes management programs as a means of addressing the dual challenge of achieving/maintaining control of glucose levels and preventing or delaying the onset of complications. Programmatic integrated approaches have been used successfully and cost-effectively for managing other chronic conditions. Incorporating rtCGM in similar integrated approaches in diabetes management may be of value in improving quality outcomes and reducing costs on a population level. The evidence supports broader adoption and continued study to evaluate models that incorporate the use of rtCGM.

Nasoseptal Surgery Outcomes in Smokers and Nonsmokers.

Background: Many surgeons refuse to perform elective nasal surgery in active smokers, but little literature exists that addresses the risks of doing so; we sought to quantify the differences in outcomes after nasal surgery among smokers, previous smokers, and nonsmokers by measuring complication rates, revision rates, and improvement in Nasal Obstruction Symptom Evaluation (NOSE) scores. Methods: We performed a single institution retrospective review of patients undergoing nasoseptal surgery. Specifically, we noted demographic characteristics, smoking status, surgery type, and pre- and postoperative NOSE scores. We compared NOSE scores, complication rates, and revision rates among current smokers, previous smokers, and never smokers. Results: Five hundred thirty patients were included for complication and revision rate analysis; there was no difference in complication or revision rates among patients of different smoking categories. Two hundred ninety-one patients completed pre- and postoperative NOSE scores. Scores for all surgeries and in all smoking categories improved postoperatively (p < 0.001). There was a difference in NOSE score change among surgical groups, with rhinoplasty resulting in the greatest improvement (p = 0.044). There was no difference in NOSE score improvement across smoking categories. Conclusion: Active smokers benefit from surgical intervention and can expect a similar improvement in nasal breathing to their nonsmoking counterparts if they meet indications for and undergo nasal surgery.

Management of a mucocoele of the submandibular gland without removal of the gland: a case report.

A mucocoele or extravasation of mucus is common in minor salivary glands, but unusual in major ones. Those from the submandibular gland are a diagnostic challenge and conventional management includes excision of the associated gland. We describe a 27-year-old man with a mucocoele of the submandibular gland that presented as a lateral cervical swelling and looked like a plunging ranula. The cystic lesion was completely excised and, to our knowledge, this is the first published case in which the submandibular gland was saved with no recurrence up to two years postoperatively.

Hemangiomas of infancy: treatment of ulceration in the head and neck.

Ulceration is a common complication of hemangiomas of infancy and presents a therapeutic dilemma for the head and neck-facial plastic surgeon. Multiple therapies are available, further complicating treatment of patients. We review the common characteristics of ulcerated hemangiomas and discuss the treatment modalities available. We present case reports to illustrate management options and a stepwise algorithm for treatment of ulcerated hemangiomas.

Impact of diabetic foot ulcer on health-related quality of life: A cross-sectional study.

Studies have reported that health-related quality of life (HRQoL) is adversely affected by diabetic foot ulcer (DFU). There is a paucity of data on the effects of foot ulcers on HRQoL of diabetes patients in our population. Because South-Asians, especially Indians, have unique features related to diabetes and its complications, generalizing the data about their effect on HRQoL from any other part of the world is not a pragmatic approach. This study evaluated the impact of foot ulcers on HRQoL of diabetes patients. This cross-sectional study, conducted in Kasturba Hospital, Manipal (coastal South India), included 200 DFU patients in a study group (SG) and 200 diabetes patients in a control group (CG). The RAND-36 questionnaire was employed for evaluating HRQoL scores for the patients in both groups. DFU patients also completed the Diabetic Foot Ulcer Scale-Short Form questionnaire. Independent t-test was used to test the differences in mean scores. Results found that both CG and SG have "poor" HRQoL (mean score <50) on all the subscales except for two in CG. There is a statistically significant difference between groups (P < 0.05) on all eight of the subscales of HRQoL. For both CG and SG, the Physical Component Summary domain score (44.9 ± 6.3 v 28.4 ± 3.4) and Mental Component Summary domain score (42.5 ± 3.8 v 29.5 ± 7.1) were poor. There were significant differences between CG and SG for both mean Physical Component Summary score and Mental Component Summary score of HRQoL (p < 0.05). The Diabetic Foot Ulcer Scale-Short Form found that HRQoL is very poor for DFU patients on all six domains. The study concludes that DFU patients have very poor HRQoL compared with diabetic patients. Likewise, the diabetic foot is associated with severely impaired HRQoL in both physical and mental health aspects. This study will help to develop a patient education model for DFU patients by looking at the various HRQoL domains that are adversely affected by the presence of foot ulcer.

Pre-emptive effect of dexamethasone injection and consumption on post-operative swelling, pain, and trismus after third molar surgery. A prospective, double blind and randomized study.

AIM: To evaluate the preventative effect of intravenous 4 mg of dexamethasone and 8 mg oral dexamethasone on post-operative pain, swelling and trismus after the surgical extraction of mandibular third molars. MATERIALS AND METHODS: A randomized clinical trial comprised of 200 patients (control group I intravenous and experimental group II orally) with impacted lower third molars, average age 20.8 years with no local or systemic problems, with bilateral impacted lower third molars, were operated under local anesthesia. Group I was given 4 mg IV and group II was given 8 mg orally of dexamethasone 1 h before procedure. The choice of which side to operate first and the amount of concentration of medication to use was made randomly and double-blindly. Post-operative pain was evaluated using a visual analog scale (VAS) and the degree of swelling was evaluated through facial reference points' variation. The presence of trismus was analyzed through measurement of the interincisal distance (IID). These assessments were obtained before the operation and 24 h, 48 h and 7th POD. RESULTS: No significant difference was found in facial swelling and trismus between IV 4 mg injection and oral 8 mg consumption after lower third molar surgery (student t test P > 0.05). The visual analogue scale scores for pain assessment showed no significant difference between IV injection and oral route of dexamethasone (student t test P > 0.05). CONCLUSION: Patients can be administered 8 mg oral dexamethasone is as effective as 4 mg intra venous route without much difference in final outcome at any given point of time.

Fractures of the mandibular condyle--Open versus closed--A treatment dilemma.

PURPOSE: The aim of this prospective randomized controlled study was to evaluate the superiority of open method of treatment of mandibular condylar fracture over closed method of treatment by comparing them. METHODS AND PATIENTS: Out of a total of 50 randomized patients fractures of the mandibular condylar process completed the study and were evaluated. All fractures were displaced, being either angulated between 10° and 45°. The follow-up examinations 1st day, 2nd day, 1st week, 2nd week, 6th week, and 6 months following treatment included clinical evaluation of functional and subjective parameters including visual analogue scale for pain and the interincisal mouth opening, malocclusion, deviation of mouth, range of motion, radiographic measurements were done. RESULTS: No significant difference was found between the two groups in the maximal interincisal opening, range of movements and TMJ pain. However statistically significant difference was seen in the anatomic reduction of condyle, shortening of ascending ramus, occlusal status and deviation on mouth opening on immediate postoperative phase. CONCLUSION: Both treatment options for condylar fractures of the mandible yielded acceptable results. However, a statistically significant difference was seen in the anatomic reduction of the condyle and there was no deviation on maximum mouth opening in patients treated with open reduction and internal fixation which suggests its superiority over closed method.

Endoscopic image-guided transethmoid pituitary surgery.

OBJECTIVE: We describe a new endoscopic transethmoid approach for pituitary surgery and to compare it with other surgical techniques. STUDY DESIGN AND SETTING: Eleven patients undergoing pituitary surgery from September 2000 through January 2002 underwent an image-guided endoscopic transethmoid procedure to remove pituitary tumors. Ease of approach, resection, exposure of the surgical field, and operative complications were documented. RESULTS: Endoscopic ethmoidectomy permits enhanced exposure and simplified tumor resection. The use of one nostril to stabilize the endoscope and the other to pass instruments affords a bimanual procedure that avoids the difficulty of small nares and keeping the scope fixed while exchanging instruments. Operative morbidity was low with no significant complications in this pilot study. CONCLUSIONS: This approach opens a generous operative exposure while safely allowing room to endoscopically maneuver and affords direct access should revision surgery be needed. SIGNIFICANCE: This procedure uses a technique familiar to otolaryngologists and may be used for pituitary and other skull base tumors.

Osteochondroma of the mandibular condyle - Report of an atypical case and the importance of computed tomography.

Osteochondroma is a rare tumor of the mandibular condyle. Much confusion seems to exist in the literature in differentiating these tumors from chondromas as well as condylar hyperplasias. Due to considerable overlapping features between chondromas and condylar hyperplasia, it is likely to get misdiagnosed, thereby resulting in inadvertent errors in the treatment. A case report of a 35 year old male patient with mandibular deviation and malocclusion is presented here. He initially went unnoticed for features of an osteochondroma of the mandibular condyle but was subsequently treated for the same.

Diagnosing aerodynamic supraglottic collapse with rest and exercise flexible laryngoscopy.

OBJECTIVE: Laryngomalacia is best known as a self-resolving infantile disorder characterized by inspiratory stridor with occlusion of the larynx by collapse of arytenoid tissues due to Bernoulli forces. Adult laryngomalacia has been sporadically described in the literature. We identified a series of patients with aerodynamic supraglottic collapse mimicking laryngomalacia in our Otolaryngology clinic. STUDY DESIGN: Case series. METHODS/PATIENTS: A series of five patients from our Otolaryngology clinic with aerodynamic supraglottic collapse presented with complaints ranging from noisy breathing to dyspnea with exertion. Diagnosis was made using rest and exercise flexible laryngoscopy. RESULTS: Symptoms resolved in all patients who underwent traditional or modified supraglottoplasty. CONCLUSIONS: These patients, all with abnormal corniculate/cuneiform motion occluding the airway during forceful inspiration, reinforce the diagnostic role of rest and exercise flexible laryngoscopy in patients with dyspnea and stridor. These results may suggest that aerodynamic supraglottic collapse is an underdiagnosed clinical entity.