A Clinical-Anatomical-Radiological Study of Extraperitoneal Spaces: A Case Series.

Complications can arise secondary to anorectal suppurative diseases, with infections spreading along the extraperitoneal space, such as the peri-vesical, prevesical, pre-sacral, and pararectal spaces, resulting in abscesses at remote sites, which can make diagnosis more challenging. Due to the absence of peritonitis symptoms, there is a delay in presentation among such patients. Comprehending the intricacies of these areas and the way infection can spread within them is crucial for promptly identifying and effectively draining the extraperitoneal abscess. We present a case series of six patients with a mean age of 45, all males. A total of three patients had undergone incision and drainage after being diagnosed with anorectal suppurative disease and remained symptomatic after the initial surgical intervention of incision and drainage. Two patients initially diagnosed with anterior abdominal abscesses patients, after being treated with incision and drainage, continued to have purulent discharge from the drainage site. Finally, the last patient continued to present with perianal pain after an open hemorrhoidectomy. CT scans of all six patients showed collections in the extraperitoneal spaces correlated with the observed complications. To deepen our understanding of pelvic extraperitoneal spaces, cadaver dissections were conducted and compared with CT images. Through cadaver dissections and CT imaging, the study provides insights into the anatomy and interconnections of pelvic extraperitoneal spaces, emphasizing the importance of early CT scans for diagnosis. Understanding these intricate anatomical structures is essential for accurate diagnosis and efficient and effective treatment. Timely diagnosis is vital to prevent prolonged illness and reduce the risk of complications and mortality. The importance of early CT scans in suspected patients is underscored, which is highly important to expedite appropriate actions.

Multi-Generation Ecosystem Selection of Rhizosphere Microbial Communities Associated with Plant Genotype and Biomass in Arabidopsis thaliana.

The role of the microbiome in shaping the host's phenotype has emerged as a critical area of investigation, with implications in ecology, evolution, and host health. The complex and dynamic interactions involving plants and their diverse rhizospheres' microbial communities are influenced by a multitude of factors, including but not limited to soil type, environment, and plant genotype. Understanding the impact of these factors on microbial community assembly is key to yielding host-specific and robust benefits for plants, yet it remains challenging. Here, we conducted an artificial ecosystem selection experiment for eight generations of Arabidopsis thaliana Ler and Cvi to select soil microbiomes associated with a higher or lower biomass of the host. This resulted in divergent microbial communities shaped by a complex interplay between random environmental variations, plant genotypes, and biomass selection pressures. In the initial phases of the experiment, the genotype and the biomass selection treatment had modest but significant impacts. Over time, the plant genotype and biomass treatments gained more influence, explaining ~40% of the variation in the microbial community's composition. Furthermore, a genotype-specific association of plant-growth-promoting rhizobacterial taxa, Labraceae with Ler and Rhizobiaceae with Cvi, was observed under selection for high biomass.

Factors Influencing the completion of 2 years of rural service by MBBS graduates at an Indian medical college - A qualitative study.

Background: Physician shortage in rural areas is a global problem that is one of the contributors to disparities in health indicators between rural and urban areas. The medical college to which the authors are attached has a 2-year mandatory rural service requirement which medical graduates are expected to fulfil. However, some students choose the option of paying off rather than completing the service requirement. The objective of this study was to explore the facilitating factors and barriers for MBBS graduates from the above medical college to complete the mandatory rural service requirement. Methods: This was a qualitative study in which data was collected through in-depth interviews with 15 alumni of the college who were pursuing their postgraduate courses or working as junior residents. The participants in the study comprised those who completed or partially fulfilled the rural service requirement as well as those who chose to opt out of it. Data collection and analysis were done in August and September 2016 after obtaining ethical clearance from the Institutional Ethics Committee. Purposive sampling was done to ensure the diversity of responses. A semi-structured interview guide was used to conduct the interviews after pilot testing. Transcripts of the interviews were then analyzed for emergent themes related to the objective of the study. Results: Certain themes were identified as both facilitating and inhibiting factors for completing the rural service requirement. These included financial aspects, utilization of time, and peer influences. Facilitating factors included the need to acquire clinical and practical skills, moral considerations, the influence of the college, and the need to broaden perspectives. Unforeseen exigencies served as a barrier. Discussion: The identified facilitating factors and barriers will serve as a useful starting point to initiate measures to encourage MBBS graduates to work in rural areas.

Effectiveness of blended learning in radiological anatomy for first year undergraduate medical students.

PURPOSE: The aim of the study was to assess the effectiveness of blended learning modules for radiological anatomy among first-year medical students by estimating knowledge gain and evaluating student perceptions. METHODS: A single-group, pre- and post-test study design was utilized. Five radiological anatomy modules consisting of online presentations and self-assessment quizzes were developed for the upper limb, lower limb, head and neck, thorax, and abdomen and pelvis. The content of the modules was uploaded on to a learning management system called TYRO. Each module focused on the normal anatomical features observed on plain and contrast radiographs. Other relevant imaging modalities and clinical contexts were also introduced. During the classroom session, the students were instructed to peruse the modules and answer the self-assessment quiz. The teacher in the classroom acted as a facilitator and was available to the students for any clarifications. A pre- and post-test was administered to the students before and after exposure to the modules, respectively. A paired t test was used to estimate differences in the pre- and post-test scores. Students' perceptions were assessed using a questionnaire. RESULTS: One-hundred students attended both the tests. The mean and standard deviation of pre- and post-test scores were 17 ± 5.5 and 26 ± 7.6, respectively, and this difference was significant. Students' perceptions about the intervention were on the whole positive. CONCLUSION: A significant improvement in the knowledge of radiological anatomy was noted after exposure to five blended learning modules of radiological anatomy. The modules were well received by the students.

Publisher Correction: Host-associated microbiomes are predicted by immune system complexity and climate.

Following publication of the original paper [1], it was reported that an error in the processing of Fig. 8 occurred. In the online HTML version of the article, Fig. 8 was presented as a duplication of Fig. 7. The original article [1] has been corrected.

Host-associated microbiomes are predicted by immune system complexity and climate.

BACKGROUND: Host-associated microbiomes, the microorganisms occurring inside and on host surfaces, influence evolutionary, immunological, and ecological processes. Interactions between host and microbiome affect metabolism and contribute to host adaptation to changing environments. Meta-analyses of host-associated bacterial communities have the potential to elucidate global-scale patterns of microbial community structure and function. It is possible that host surface-associated (external) microbiomes respond more strongly to variations in environmental factors, whereas internal microbiomes are more tightly linked to host factors. RESULTS: Here, we use the dataset from the Earth Microbiome Project and accumulate data from 50 additional studies totaling 654 host species and over 15,000 samples to examine global-scale patterns of bacterial diversity and function. We analyze microbiomes from non-captive hosts sampled from natural habitats and find patterns with bioclimate and geophysical factors, as well as land use, host phylogeny, and trophic level/diet. Specifically, external microbiomes are best explained by variations in mean daily temperature range and precipitation seasonality. In contrast, internal microbiomes are best explained by host factors such as phylogeny/immune complexity and trophic level/diet, plus climate. CONCLUSIONS: Internal microbiomes are predominantly associated with top-down effects, while climatic factors are stronger determinants of microbiomes on host external surfaces. Host immunity may act on microbiome diversity through top-down regulation analogous to predators in non-microbial ecosystems. Noting gaps in geographic and host sampling, this combined dataset represents a global baseline available for interrogation by future microbial ecology studies.

Medical student's perception to different types of set induction in anatomy lectures.

Set induction refers to the process of using a thought-provoking statement, interesting fact, or an audio-visual stimulus at the beginning of lecture to gain student's attention and give an overview about the lecture topic. In the present study, students were introduced to three types of set induction namely narratives, food-based analogies and humor-based images or activities at the beginning of anatomy lecture and their response to it is collected and analyzed. The objective of the study is to estimate the difference in a questionnaire-based perception score between the three different types of set induction; estimate sex differences in the questionnaire-based perception score. Students rated the validated, 7-item perception questionnaire using a 5-point Likert scale. Students felt that food-based analogies and humor-based images were more interesting, motivated them to participate in lecture-discussion than the narrative set induction. The familiarity of set induction varied between all the three different types of set induction. There was no significant difference in the perception of different types of set induction between male and female undergraduate students. Based on the student's feedback, it could also serve as a memory aid and ease the students learning experience. Majority of students responded positively to the use of set induction and recommended for its use in future classes.

Peer-assisted learning versus didactic teaching in osteology for first-year Indian undergraduate medical students: a quasi-experimental study.

PURPOSE: The utility of peer-assisted learning (PAL) in anatomy education has been recognized. In this study, PAL was incorporated into osteology teaching for the first-year medical students and compared to traditional didactic methods (TDM). METHODS: This was a cross-over intervention study. The class of 60 students was divided into two equal groups. The first group underwent PAL for five upper limb osteology sessions and TDM for all lower limb osteology classes. The second group underwent TDM for five upper limb osteology classes and PAL for lower limb osteology classes. A pre-session test (PrST) and post-session test (PoST) were conducted for each session using multiple choice type questions. Perceptions of students about PAL were collected using a questionnaire. Between and within group differences were estimated using the independent sample T test and paired T test, respectively. The responses in the questionnaire were summarized and open-ended responses categorized into broad themes. RESULTS: Greater group differences were noted in the PrST as compared to the PoST mean scores, with the PAL group showing higher mean scores for both upper and lower limb sessions. Significantly higher PoST scores compared to PrST scores for all the sessions were observed regardless of the method used. Significantly higher scores in the PrST or PoST scores were noted in the PAL group for five sessions. Most aspects of PAL were appreciated by the students. CONCLUSIONS: This study provides evidence that PAL is at least as effective as TDM in learning osteology among the first-year medical students.

Effects of targeted remediation in anatomy for first year medical students.

The aim of this study was to assess the effectiveness of a questionnaire to guide targeted remediation among undergraduate medical students in anatomy. Seventy-five students from a medical college in South India who failed in the first internal theory examination were administered a validated 35-item questionnaire. The total and domain specific questionnaire scores were calculated. Specific weekly interventions for each student based on the questionnaire scores were conducted by appointed academic mentors for three months prior to the second internal examination. The dependent variable was performance in the second internal examination. The students were re-administered the questionnaire after the second internal examination. The independent variables were the marks obtained in the first internal examination, domain specific and total questionnaire scores, sex, and regularity of the student in attending the remedial sessions. Inferential statistical tests used were the chi-square test, independent sample t test, paired t test, multiple regression and binomial logistic regression. Of the 75 students who underwent remediation, 54 (72%) passed in the second internal examination. The scores in the second internal examination among these students was found to be significantly higher as compared to the first internal examination. The total, subject related and study skills questionnaire score were significantly lower after remediation. Students who were irregular had a significantly lower pass rate. The multivariate analysis showed that only the first internal marks added significantly to the prediction about second internal performance. This study provides evidence to show that struggling students perceive a benefit from targeted remediation.

Efficacy of modified Tochen's formula for optimum endotracheal tube placement in low birth weight neonates: an RCT.

OBJECTIVE: To assess the efficacy of modified Tochen's formula (birth weight + 5 cm) when compared to Tochen's formula for optimum placement of endotracheal tubes (ET) in low birth weight (LBW) neonates. STUDY DESIGN: In the NICU of a tertiary care hospital, LBW babies requiring intubation were randomized to Tochen's formula or modified Tochen's formula. The incidence of inadequate placement and optimum length of ET insertion were estimated. Analysis was done by the Chi square and 't'-tests. RESULTS: Sixty-seven babies were included: 34 in Tochen's group and 33 in modified Tochen's group. Baseline characteristics were similar. Modified Tochen's formula was significantly (p = 0.006) closer to the optimum position when compared to Tochen's formula. The percentages of optimum and adequate placements of the ET tube was higher in the modified Tochen's group, though not statistically significant. CONCLUSION: Modified Tochen's formula in LBW babies may enable more optimum placement of ETs.

Absent external oblique musculo-aponeurotic complex during inguinal hernioplasty: a case report and review of literature.

The external oblique musculo-aponeurotic complex is an important contributor to the strength of the inguinal canal. The present case report describes the bilateral absence of the external oblique muscle in a patient. A 40-year-old male patient presented with a history of intermittent lower abdominal pain for 15 years which had increased over the past 2 years. Abdominal examination revealed bilateral reducible, incomplete, direct inguinal hernia. Elective bilateral Lichtenstein's mesh hernioplasty was planned for the patient. Intraoperatively, there was no evidence of the external oblique aponeurosis and the spermatic cord was noted deep to the membranous fascial layer. The inguinal ligament was thin and atrophic and was attached to the pubic tubercle medially and anterior superior iliac spine laterally. There was no evidence of any superior aponeurotic connection to the inguinal ligament. A postoperative ultrasound examination of the abdomen confirmed the bilateral absence of the external oblique musculo-aponeurotic complex. The isolated absence of the external oblique musculo-aponeurotic complex in adults is an exceedingly rare anomaly. The possibility of such an anomaly should be considered in patients without other risk factors for hernia.

Morphometry of the triangle of Koch and position of the coronary sinus opening in cadaveric fetal hearts.

AIMS: The aim of the present study was to determine the variations in the position of the coronary sinus (CS) ostium in normal cadaveric fetal (28 weeks or more) hearts and to assess the impact that these variations had on the dimensions of the triangle of Koch (TK). METHODS: This cross-sectional analytical study was conducted on 28 fetal hearts. The dimensions and area of the TK were calculated by two methods, M1 (anatomical) and M2 (clinical). The position of the CS was defined with respect to the tendon of Todaro. Differences between M1 and M2 were estimated using the paired T test. Pearson's correlation coefficient and the adjusted correlation coefficient were used to estimate the strength of association between measurements made by the methods. RESULTS: Ten (35.7%) cadavers were male and 18 (64.3%) female. The mean gestational age was 32.4±3.3 weeks. Using M1, the mean dimensions of the triangle in millimeters (mm) were 9.2±2.2, 6.6±1.8, and 6±2.4 respectively for a, b and c. Similarly, the dimensions using M2 were 7±2.1, 4.7±1.5, and 4.8±2.2. The area in mm2 was 20.4±10.4 and 11.7±6.7 using M1 and M2 respectively. All measurements were significantly greater with M1. All correlation coefficients were high and significant. The CS ostium and tendon of Todaro maintained a relatively constant positional relationship. CONCLUSIONS: Significantly higher values were noted in the dimensions of TK using M1. High significant positive correlations were observed in measurements made by the two methods. The CS ostium was relatively constantly placed within the TK.

Effective and Economic Offloading of Diabetic Foot Ulcers in India with the Bohler Iron Plaster Cast.

Economic constraints are a major obstacle to the implementation of offloading casts in India. The aim of this study is to monitor the healing and activity limitations related to Bohler iron plaster cast (BIPC) when used for offloading diabetic neuropathic plantar foot ulcers. Thirty patients were cast for 1 month and evaluated for healing using the Pressure Ulcer Scale for Healing (PUSH), and for activity limitation using the Lower Extremity Functional Scale (LEFS). The change in the scores after intervention was the outcome measure. There was good healing as evidenced by a statistical difference in mean PUSH scores. The baseline PUSH score of 9.76-0.41 (T1-SEM) was greater than follow-up PUSH score of 6.32 + 0.41 (T2 + SEM) and the p value <0.0001. Improvement was seen in ulcer area, exudate, and tissue type. There was no mobility effect as there was no significant difference in LEFS. Significant negative correlation was there between PUSH and LEFS. The r value was less than -0.7 both at baseline and after intervention. The combined benefits of good healing, lack of affect on lower extremity function, the ease of application and dressing, and relative affordability make BIPC a commendable offloading modality for the management of diabetic plantar ulcers.

Evaluation of body parameters for estimation of endotracheal tube length in Indian neonates.

UNLABELLED: The objectives were to estimate the incidence of inadequate placement of the endotracheal tube (ET) using Tochen's formula (6 + birth weight) and to correlate optimum ET length with anthropometric measurements in neonates. A cross-sectional analytical study was conducted in 50 neonates. Neonates requiring intubation for ventilation, with a confirmatory chest radiograph, were intubated using Tochen's formula, after which tube placement was verified by auscultation. The incidence of inadequate placement and optimum length of ET insertion were estimated from chest radiographs. Anthropometric parameters were measured and correlated with the optimum length and regression equations generated. The incidence of inadequate placement of the ET was 40 % (20 of 50). The incidence of inadequate placement was higher (5 of 6, 83 %) in extremely low birth weight (ELBW) infants, and in extreme preterm infants (5 of 5, 100 %). It was found that all the anthropometric parameters correlated well (r between 0.71 and 0.84) with the optimum ET length. CONCLUSION: The incidence of inadequate placement was high, especially in the ELBWs' and extreme preterm infants. Birth weight, sternal length, and shoulder umbilical length correlated significantly with optimum ET length and may guide optimal ET placement.

Influence of skin-to-muscle and muscle-to-bone thickness on depth of needle penetration in adults at the deltoid intramuscular injection site.

BACKGROUND: THE OBJECTIVES OF THE STUDY WERE TO ESTIMATE THE FOLLOWING IN ADULTS OF INDIAN ORIGIN: a) Gender and side differences in the skin-to-muscle (SM) and muscle-to-bone thickness (MB) at the deltoid intramuscular injection site; b) Correlation of SM thickness with the BMI, age and gender; c) The prevalence of under and over-penetration assuming a standard needle length of 25 mm and following prescribed guidelines for IM injection. METHODS: The SM, MB and skin-to-bone (SB) thicknesses were bilaterally estimated in two hundred adult Indian subjects (100 male and 100 female) using an ultrasound probe at a pre-determined point on the upper arms of the subjects. The BMI of each subject was calculated. The unpaired sample 't' test and paired 't' test were used to analyse differences between groups. Pearson's correlation coefficient was used in correlation analysis and suitable linear regression equations were generated. RESULTS: Females had a significantly higher SM thickness and lower MB thickness. The SM thickness was significantly greater on the left side, while the SB and MB thickness were significantly greater on the right. Multiple linear regression equations for both the dominant and non-dominant arms had good model fit properties. Under-penetration would have occurred in 2 (1%) subjects while over-penetration would have occurred in 50% of the subjects. CONCLUSION: Over-penetration of deltoid IM injections is likely to be more prevalent as compared to under-penetration. Therefore, the technique of IM injection needs to be modified based on the body type of the individual patient.

Anatomical variations of the pre-transverse segment of the vertebral artery in Indian cadavers

Variations of the first segment (V1) of the vertebral arteey (VA) are important to spine surgeons and radiologists. The present study was conducted to document the anatomical variations of the V1 segment and estimate side and gender differences, if any. The study was a cross-sectional analytical study performed on 33 adult cadavers (24 male and 9 female) of Indian origin. The V1 segment of 67 VA was dissected and the following parameters were noted: site of origin, level of entry into cervical spine, presence of tortuosity, length, external diameter and presence of hypoplasia. Side differences were estimated using the paired sample T test and Wilcoxon signed rank test. The independent sample T test and Chi square test were used to estimate gender differences. An unusual origin of the right VA from the thyrocervical trunk, in addition to the origin of the left VA from the arch of the aorta, was noted. Stenotic segments were observed in 4.5% of the VA. Rare levels of entry into the cervical column of the V1 segment of the VA included the foramen transversarium of C5 (4.5%) and C7 vertebra (2.5%). Nine per cent of V1 segments showed a high degree of tortuosity. The mean length and diameter of the V1 segments were 3.7±1.5 cm and 4.2±0.9 mm respectively. Hypoplasia was observed in 18% of the V1 segments. The mean length of the V1 was found to be significantly greater on the left side. Male cadavers had a significantly greater external diameter of V1. The knowledge of these variations of the V1 segment of the VA is imperative for the safe performance of anterior spine procedures

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The evolution of bacterial DNA base composition.

Bacterial genomes exhibit a large amount of variation in their base composition, which ranges from 13% to 75% GC. The evolution and maintenance of this variation has proved to be an enduring puzzle despite decades of theoretical and empirical work. We present an overview of various aspects of this problem, focusing on results from a diverse set of recent studies that use whole-genome sequencing in combination with bioinformatic, phylogenetic, molecular biological, and experimental evolution approaches. We propose that analysis of within-genome variance in GC content is also important to understand how genome-wide base composition has evolved. We close with a discussion of open questions and fruitful avenues of inquiry that may bring us closer to understanding the evolutionary dynamics of bacterial DNA base composition.

Complete unilateral right-sided absence of the pectoralis major and serratus anterior muscles in an adult male cadaver of South Indian origin.

The unilateral complete absence of the pectoralis major and serratus anterior muscles in the absence of other anomalies is very rare. The complete absence of the pectoralis major and serratus anterior on the right side was observed during routine dissection of an elderly male cadaver of South Indian origin. Nodularity of the right fifth rib near the fifth costochondral junction was seen. The lateral pectoral and long thoracic nerves were present on the right side. Moderate right-sided disuse atrophy was noted in the pectoralis minor and the rotator cuff muscles due to a shoulder arthrodesis performed on that side. No abnormalities were noted on the left side. There was no family history of any upper limb anomalies suggestive of Poland's syndrome. The findings in the present case could be either due to a sporadic variant of Poland's syndrome or an isolated congenital unilateral absence of the pectoralis major and serratus anterior.

Bilateral single cord of the brachial plexus in an adult female cadaver of South Indian origin.

The occurrence of a brachial plexus united into a single cord is very rare. During routine dissection of an elderly female cadaver, the brachial plexus united into a single cord was observed bilaterally. On the left side, C4, C5, and C6 roots combined to form the upper trunk, the C7 root continued as the middle trunk, and C8 and T1 united to form the lower trunk. All three trunks almost immediately fused to form a single cord. On the right side, C5 and C6 roots joined to form the upper trunk, which divided into anterior and posterior divisions. C7, C8, and T1 roots combined to form the lower trunk. The anterior and posterior divisions united with the lower trunk to form a single cord. On both sides, the subclavian artery was superior to the single cord. Supraclavicular brachial plexus injuries in such individuals may have serious clinical manifestations.

Near complete tracheal rings in an adult male cadaver associated with variation in V2 and V3 segments of vertebral artery

During routine dissection in an adult male cadaver, the presence of long segment near complete tracheal rings associated with variation in the second (V2) of right vertebral artery (VA) and third (V3) segments of the left VA was encountered. This case report highlights the normal lifespan of an individual despite anatomical variations that are reported to be incompatible with life. Congenital complete and near-complete tracheal rings are extremely rare tracheal deformities, and long-segment occurrences of these variations are usually incompatible with life. They are reported to be associated with cervical chondrogenic anomalies and craniosynostotic syndromes.In the same cadaver the left VA entered the foramen transversarium (FT) of C6 vertebra and exited through the FT of the axis. It formed a loop below the arch of atlas and entered the vertebral canal between the atlas and axis, completely bypassing the FT of the atlas. A branch from the loop divided into two branches, one of which supplied the dorsal ramus of C1, the other ending in the surrounding neck musculature. The right VA was normal, except that it entered the FT of C5 vertebra bypassing C6 vertebra. It was noted that the calibre of the VA on the left side was considerably more than that on the right. Variations in the vertebrobasilar system have a potential clinical impact, since they are the feed arteries of the brain (AU)

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