Suture Button Repair for Lateral Ulnar Collateral Ligament in Terrible Triad Injuries: Surgical Technique.

Terrible triad injuries are typically treated surgically to restore elbow stability, as the radial head acts as a secondary stabilizer to valgus stress, while the coronoid provides stability against posterior elbow dislocations. The lateral ulnar collateral ligament (LUCL) is also commonly injured in terrible triad of the elbow injuries, and if not repaired, leads to posterolateral rotatory instability. Depending on the fracture pattern and size, the radial head fracture may be treated with open reduction internal fixation (ORIF), arthroplasty, or excision, whereas the coronoid fracture is most commonly treated with ORIF. If treated, these injuries are managed prior to LUCL fixation to avoid stressing the LUCL repair. We describe a technique for treatment of a LUCL injury with a suture button. When repairing the LUCL, a Kocher approach is used to visualize the LUCL footprint, which is then reattached to the insertion point on the lateral epicondyle using a suture button. The purpose of this study was to provide a step-by-step approach to using this surgical technique and an associated postoperative protocol.

Recurrence Rates of Dorsal Wrist Ganglion Cysts After Arthroscopic Versus Open Surgical Excision: A Retrospective Comparison.

BACKGROUND: This study directly compares the recurrence rates of dorsal wrist ganglion cysts in patients treated via open surgical excision versus arthroscopic surgical excision. We hypothesized that there would be no difference between recurrence rates with these 2 surgical options. METHODS: We retrospectively reviewed the charts of all patients with a dorsal ganglion cyst undergoing either open or arthroscopic surgical excision at a single academic center with 3 fellowship-trained attending hand surgeons from 2012 to 2017. Charts were identified using Current Procedural Terminology codes and were reviewed using postoperative office notes for preoperative and postoperative symptoms, episodes of recurrence, time at which recurrence occurred, subsequent operations, and outcome at final follow-up. RESULTS: The charts of 172 patients undergoing either arthroscopic or open dorsal ganglion excision were reviewed. Nine of 54 (16.7%) arthroscopic excisions resulted in cyst recurrence, while 8 of 118 (6.8%) open excisions resulted in cyst recurrence (P = .044). Two of 9 (22%) recurrences after arthroscopic ganglion excision versus 2 of 8 (25%) recurrences after open ganglion excision underwent repeat surgical intervention. Time to recurrence, as well as final follow-up, was not statistically different between groups. CONCLUSIONS: Dorsal wrist ganglion cysts are the most common benign soft tissue mass of the upper extremity, but it remains unknown whether arthroscopic or open surgical excision leads to lower recurrence rate. Scant literature exists directly comparing these 2 methods of surgical excision. This study suggests that open excision of dorsal wrist ganglia leads to a lower recurrence rate than does arthroscopic excision.

Performance of various mathematical functions for the in-situ relative detector efficiency towards its applicability for k0 IM-NAA.

The in-situ relative detection efficiency strongly influences the characteristics of the k0-based internal monostandard neutron activation analysis (IM-NAA). In the present work, various mathematical functions were explored for the establishment of in-situ relative detector efficiency calibration and compared their performance based on the reduced chi-square (χ2) values. Among the various mathematical functions, the polynomial logarithm with 6th order was found to be associated with the minimum mean standard deviation for the experimental data and the lowest value of reduced χ2 after carrying out multiple iterations using Nelder-Mead algorithm. Quality assurance of the function was tested by carrying out elemental quantification of the NIST SRM 1633b coal fly ash. Gamma energies of the activation products, 152mEu, 59Fe, 140La, 24Na and 46Sc of the irradiated NIST standard were used for the in-situ relative full energy peak efficiency calibration of 30% HPGe detector. The sample was counted for different time intervals for the complete profiling of the elements present in the NIST SRM. The deviations for most of the elements were found to be within ±5% with respect to the certified values and ξ-score values were within ±2, demonstrating its better accuracy. This method was also applied satisfactorily to profile the elemental concentrations of alloy materials used in a thermal sensor guide tube of the steam generator in a test reactor.

Reverse zoonosis of coronavirus disease-19: Present status and the control by one health approach.

The recent coronavirus disease (COVID-19) outbreak is one of its kind in the history of public health that has created a major global threat. The causative agent, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has a zoonotic source and hence, reverse zoonosis (disease transmission from humans to animals) increases the risk and rate of SARS-CoV-2 infection. Serological and molecular analyses and experimental infection studies have identified SARS-CoV-2 infection in several animal species in various countries. Different domestic and wild animals, including cats, dogs, tigers, lions, puma, snow leopard, minks, and pet ferrets, are infected naturally with SARS-CoV-2, mostly through suspected human to animal transmission. In addition, in vivo experimental inoculation studies have reported the susceptibility of cats, ferrets, hamsters, Egyptian fruit bats, and non-human primates to the virus. These experimentally infected species are found to be capable of virus transmission to co-housed animals of the same species. However, SARS-CoV-2 showed poor replication in livestock species such as pigs, chickens, and ducks with no detection of viral RNA after the animals were deliberately inoculated with the virus or exposed to the infected animals. As the pets/companion animals are more susceptible to COVID-19, the infection in animals needs an in-depth and careful study to avoid any future transmissions. The one health approach is the best inter-disciplinary method to understand the consequences of viral spread and prevention in novel host populations for the betterment of public health. Further in this review, we will explain in detail the different natural and experimentally induced cases of human to animal SARS-CoV-2 infection.

Economic Impact of Unused Surgical Instruments in an Orthopaedic Surgery Department at an Academic Medical Center: A Prospective Cross-sectional Study.

Orthopaedic surgical trays contain unused instruments, but we do not know which specific instruments go unused nor do we know the savings from eliminating them from a given tray. This was a single-site, observational study conducted at an academic medical center. The primary outcome was type of unused instruments and percentage of instruments used in two commonly used surgical trays. The secondary outcome was cost savings in United States dollars (USD) that could be attained by eliminating these instruments. In the first tray, five instruments (10.6%) were unused in any of 37 observed cases. In the second tray, nineteen instruments (19.6%) were unused in 37 observed cases. The total annual savings from replacement cost analysis and reprocessing cost analysis was $6,597.00 USD. Unused instruments are common in surgical trays. Eliminating unused instruments can result in immediate cost savings. (Journal of Surgical Orthopaedic Advances 30(3):131-135, 2021).

Validation of Complete Hindi Version of Douleur Neuropathique 4 Questionnaire for Assessment of Neuropathic Pain.

OBJECTIVES: The Douleur Neuropathique 4 (DN4) questionnaire is a widely used tool for the diagnosis of neuropathic pain (NP). The aim was to validate the Complete Hindi version of DN4 (CH-DN4) questionnaire. MATERIALS AND METHODS: A systematic translation process was used to translate the original English DN4 into Hindi. The Hindi version was validated among patients appearing in the pain clinic of a tertiary hospital in the capital of Delhi by two different raters. We assessed the internal consistency, test-retest reliability, and inter-rater agreement, validity, sensitivity, specificity, positive and negative predictive values, and area under the curve (AUC). RESULTS: A total of 285 participants, out of which 153 had NP and 132 had non NP (NNP) were included in the study. The results showed our CH-DN4 to have good diagnostic accuracy, a score of ≥ 3.5 was found to be the best cut-off for the diagnosis of NP, with a sensitivity of 0.78, specificity of 0.76, a positive predictive value of 78.5%, and a negative predictive value of 74.5%. Cronbach's α was 0.82 (95% confidence interval: 0.80-0.84), and interclass correlation coefficients was 0.95. The AUC was >0.8 indicating excellent discrimination between NP and NNP. CONCLUSION: The CH-DN4 questionnaire has been found to be a reliable and valid screening tool with an excellent power to discriminate between NP and NNP.

An improved parallel sub-filter adaptive noise canceler for the extraction of fetal ECG.

Non-invasive extraction of fetal electrocardiogram (FECG) by processing the abdominal signals is emerging as a promising approach in the areas of obstetrics and gynecology. This paper presents a two-stage improved non-linear adaptive filter for FECG extraction. The reference input to the adaptive noise canceler (ANC) is first processed using an adaptive neuro-fuzzy inference system (ANFIS) to estimate the non-linear maternal component in abdominal signals. A parallel sub-filter (PSF) ANC is proposed to assess the fetal ECG from the abdominal signal. The PSF-ANC decomposes a single adaptive filter into multiple sub-filters to improve the convergence performance. The filter coefficients of PSF-ANC adaptively obtained using normalised least mean square algorithm by minimizing the mean square error. Different error and common error algorithms are proposed based on the computation of the error signal. A synthetic data from the FECG synthetic database is used to evaluate the convergence performance. Two real-time data from the Daisy database and the Non-invasive FECG database from Physionet are used to evaluate the proposed ANFIS-PSF's performance qualitative and quantitatively. The results justify the performance improvement of proposed ANFIS-PSF ANC compared to the state of art techniques. The proposed scheme achieves a sensitivity of 97.92%, 94.52% accuracy, a positive predictive value of 94.66%, and an F1 score of 96.12%.

Subfascial-located contraceptive devices requiring surgical removal.

BACKGROUND: Subdermal etonogestrel implants are highly effective contraceptive methods. Despite standardization of insertion technique by the manufacturer, some implants are inadvertently placed too deeply within or below the plane of the biceps brachii fascia. Placement of these implants in a deep tissue plane results in more difficult removal, which is not always possible in the office setting. In rare cases, surgical removal by an upper extremity surgeon is warranted. CASE PRESENTATION: Here we present 6 cases of etonogestrel implants located in a subfascial plane requiring removal by an upper extremity surgeon. Implants were all localized with plain radiography and ultrasound prior to surgical removal. All cases had implants located in the subfascial plane and one was identified intramuscularly. The average age was 28 years (19-33) and BMI was 24.0 kg/m^2 (19.1-36.5), with the most common reason for removal being irregular bleeding. The majority of cases (5/6) were performed under monitored anesthesia care with local anesthetic and one case utilized regional anesthesia. All implants were surgically removed without complication. CONCLUSIONS: Insertion of etonogestrel contraceptive implants deep to the biceps brachii fascia is a rare, but dangerous complication. Removal of these implants is not always successful in the office setting and referral to an upper extremity surgeon is necessary to avoid damage to delicate neurovascular structures for safe removal.

Evaluation and Management of Hand, Wrist and Elbow Injuries in Ice Hockey.

Ice hockey continues to be a popular, fast-paced, contact sport enjoyed internationally. Due to the physicality of the game, players are at a higher risk of injury. In the 2010 Winter Olympics, men's ice hockey had the highest injury rate compared to any other sport. In this review, we present a comprehensive analysis of evaluation and management strategies of common hand, wrist, and elbow injuries in ice hockey players. Future reseach focusing on the incidence and outcomes of these hand, wrist and elbow injuries in ice hockey players is warranted.

Outerbridge-Kashiwagi Procedure for the Treatment of a Supracondylar Humerus Fracture Malunion (O-K Procedure).

The Outerbridge-Kashiwagi (O-K) procedure has conventionally been used for the treatment of osteoarthritis of the elbow and to treat posttraumatic sequelae including posttraumatic arthritis, stiffness, contracture, and ulnar neuritis. The procedure involves exposure of the posterior elbow joint as well creating a window posteriorly through the olecranon fossa to target anterior aspects of the elbow. Several case series have shown the O-K procedure to have good functional outcomes with minimal complications. Used mostly for the surgical treatment of adult osteoarthritis, the O-K procedure has not been previously described for the treatment of a pediatric supracondylar humerus fracture malunion. This article and accompanying video will present the pearls and discuss the technique of the O-K procedure used to treat the loss of elbow flexion as a sequelae of supracondylar humerus fracture malunion.

Successfully Treated Hepatitis B Positive Refractory Myasthenic Crisis with Rituximab.

Myasthenia gravis (MG) is an autoimmune disorder of neuromuscular transmission, which presents with fluctuating and variable weakness in ocular, bulbar, limb, and respiratory muscles resulting from an antibody-mediated, T-cell-dependent immunologic attack on the postsynaptic membrane of the neuromuscular junction. Although treatment of MG and myasthenic crisis is based on few specific principles, it is highly individualized. We report a successfully treated case of refractory myasthenic crisis who was on a ventilator for 7 months (210 days), perhaps the longest from India, and required multiple cycles of plasma exchange, intravenous immunoglobulin infusion, and one cycle of rituximab. It exemplifies the role of highly individualized therapy and interdisciplinary cooperation in management of refractory myasthenic crisis. HOW TO CITE THIS ARTICLE: Singh RK, Joshi D, Rath S. Successfully Treated Hepatitis B Positive Refractory Myasthenic Crisis with Rituximab. Indian J Crit Care Med 2020;24(1):71-72.

Combined Upper Extremity and Gluteal Compartment Syndrome Following Illicit Drug Abuse: A Retrospective Case Series.

INTRODUCTION: The purpose of this study was to describe four cases of patients who developed concomitant upper extremity and gluteal compartment syndrome in the context of substance abuse. In somnolent patients unable to provide a reliable physical exam, the healthcare provider must be aware of patients presenting with concomitant upper extremity and gluteal compartment syndrome. METHODS: Retrospective chart review identified cases of the combined upper extremity and gluteal compartment syndrome following illicit drug abuse at a single academic center during the years 2009-2019. RESULTS: During the 11-year period examined, a total of eight patients were diagnosed with compartment syndrome secondary to illicit drug use and prolonged immobilization. Four (50%) patients presented with combined upper extremity and gluteal compartment syndrome. All of these patients underwent prompt surgical release of the affected compartments. All eventually returned to normal activities of daily living. DISCUSSION: Compartment syndrome is primarily a clinical diagnosis, with physical exam being extremely important. In patients presenting with somnolence secondary to illicit drug use, physical exam may not be reliable. It is critical to have a high clinical suspicion in this patient population, understanding that these patients may present with concomitant upper extremity and gluteal compartment syndrome. LEVEL OF EVIDENCE: Level IV, case series.

CT of primary undifferentiated pleomorphic sarcoma of small intestine with distant metastases presenting with intussusception.

Undifferentiated pleomorphic sarcoma of bowel is very rare, only a few cases have been reported till date. A 29 year old male patient presented with acute abdominal pain due to intussusception, contrast enhanced computed tomography abdomen showed multiple endoluminal homogenously enhancing polypoidal lesions with distant metastasis. Radiologically our primary diagnosis was malignant gastrointestinal stromal tumor, however, histopathological evaluation turned out to be a small bowel undifferentiated pleomorphic sarcoma. Considering the multiplicity of lesion and early distant metastasis radiologist should also consider sarcoma involving bowel as one of the differential diagnosis.

Altered brain connectivity in sudden unexpected death in epilepsy (SUDEP) revealed using resting-state fMRI.

The circumstances surrounding SUDEP suggest autonomic or respiratory collapse, implying central failure of regulation or recovery. Characterisation of the communication among brain areas mediating such processes may shed light on mechanisms and noninvasively indicate risk. We used rs-fMRI to examine network properties among brain structures in people with epilepsy who suffered SUDEP (n = 8) over an 8-year follow-up period, compared with matched high- and low-risk subjects (n = 16/group) who did not suffer SUDEP during that period, and a group of healthy controls (n = 16). Network analysis was employed to explore connectivity within a 'regulatory-subnetwork' of brain regions involved in autonomic and respiratory regulation, and over the whole-brain. Modularity, the extent of network organization into separate modules, was significantly reduced in the regulatory-subnetwork, and the whole-brain, in SUDEP and high-risk. Increased participation, a local measure of inter-modular belonging, was evident in SUDEP and high-risk groups, particularly among thalamic structures. The medial prefrontal thalamus was increased in SUDEP compared with all other control groups, including high-risk. Patterns of hub topology were similar in SUDEP and high-risk, but were more extensive in low-risk patients, who displayed greater hub prevalence and a radical reorganization of hubs in the subnetwork. SUDEP is associated with reduced functional organization among cortical and sub-cortical brain regions mediating autonomic and respiratory regulation. Living high-risk subjects demonstrated similar patterns, suggesting such network measures may provide prospective risk-indicating value, though a crucial difference between SUDEP and high-risk was altered connectivity of the medial thalamus in SUDEP, which was also elevated compared with all sub-groups. Disturbed thalamic connectivity may reflect a potential non-invasive marker of elevated SUDEP risk.

Complete mitogenome reveals genetic divergence and phylogenetic relationships among Indian cattle (Bos indicus) breeds.

Indigenous cattle of India belong to the species, Bos indicus and they possess various adaptability and production traits. However, little is known about the genetic diversity and origin of these breeds. To investigate the status, we sequenced and analyzed the whole mitochondrial DNA (mtDNA) of seven Indian cattle breeds. In total, 49 single-nucleotide variants (SNVs) were identified among the seven breeds analyzed. We observed a common synonymous SNV in the COII gene (m.7583G > A) of all the breeds studied. The phylogenetic analysis and genetic distance estimation showed the close genetic relationship among the Indian cattle breeds, whereas distinct genetic differences were observed between Bos indicus and Bos taurus cattle. Our results indicate a common ancestor for European Zwergzebu breed and South Indian cattle. The estimated divergence time demonstrated that the Bos indicus and Bos taurus cattle lineages diverged 0.92 million years ago. Our study also demonstrates that ancestors of present zebu breeds originated in South and North India separately ∼30,000 to 20,000 years ago. In conclusion, the identified genetic variants and results of the phylogenetic analysis may provide baseline information to develop appropriate strategies for management and conservation of Indian cattle breeds.

Flexor Tenosynovitis of the Hand Caused by Mycobacterium tuberculosis.

Infectious tenosynovitis of the hand is a serious condition with a high risk of morbidity. Mycobacterium tuberculosis is a rare cause of tenosynovitis, especially in regions where tuberculosis is no longer endemic, and presents significant diagnostic challenges. We present the case of a 42-year-old woman with no known history of or exposure to tuberculosis and a medical history of systemic lupus erythematosus on chronic immunosuppressive therapy who presented with swelling and erythema in the fifth finger of the left hand of 1-month duration. She underwent tenosynovectomy, and intraoperative cultures grew M tuberculosis. The patient completed an appropriate antibiotic regimen, and systemic workup revealed ring-enhancing lesions on brain MRI consistent with tuberculoma. We review the literature and current trends in the management of mycobacterial tenosynovitis, as well as the important teaching points of the case.

Intratesticular injection followed by electroporation allows gene transfer in caprine spermatogenic cells.

The production of transgenic livestock is constrained due to the limited success of currently available methods for transgenesis. Testis mediated gene transfer (TMGT) is an emerging method that shows a high success rate in generating transgenic mice. In this study, we report a newly developed protocol for electroporation-aided TMGT to produce a transgenic goat. The injectable volume and concentration of the transgene were first standardized, and then electroporation conditions were optimized in vitro. In vivo experiments were performed by injecting a transgenic construct (pIRES2-EGFP; enhanced green fluorescent protein) into the testicular interstitium followed by electroporation. Immunohistochemistry, quantitative real-time PCR (qPCR) and western blotting analyses confirmed the successful transfer of the transgene into seminiferous tubules and testicular cells. Furthermore, chromosomal integration of the transgene and its expression in sperm were evaluated d60 and d120 post-electroporation. Our protocol neither altered the seminal characteristics nor the fertilization capacity of the sperm cells. In vitro fertilization using transgenic sperm generated fluorescent embryos. Finally, natural mating of a pre-founder buck produced a transgenic baby goat. The present study demonstrates the first successful report of an electroporation-aided TMGT method for gene transfer in goats.

The complete mitochondrial genome of Indian cattle (Bos indicus).

India has 40 distinct zebuine cattle breeds with different adaptability and production traits. In the present study, we report the complete mitochondrial genome sequence of Indian cattle for the first time. The mitogenome contains 13 protein-coding genes, 22 transfer RNA genes, two ribosomal RNA genes and a control region (D-loop region). The phylogenetic analysis showed close genetic relationship among the Indian cattle breeds studied, where as, distinct genetic differences were observed between Bos indicus and Bos taurus cattle. Our results will expand genomic information for further studies on evolution, domestication and conservation of indigenous cattle breeds in India.

Nerve and vein preserving neck dissections for oral cancers: a prospective evaluation of spinal accessory nerve function and internal jugular vein patency following treatment.

Nerve and vein preserving modification of the radical neck dissection is commonly used in the management of oral squamous cell cancers. There is limited literature addressing nerve function and vein patency following treatment. We prospectively analysed 65 patients with nerve conduction study using surface electromyography at baseline, 1 month and 6 months post-surgery and colour Doppler of the internal jugular vein at baseline and 1 month post-surgery. We also studied functional outcomes of nerve sparing with arm abduction test and Neck Dissection Quality of Life questionnaire. There was a statistically significant increase in mean latency of motor action potential and decrease in the mean amplitude of the motor action potential following surgery, suggesting nerve dysfunction. Following surgery, there was a significant decrease in the diameter of the vein as well as an increase in the velocity of blood flow; there was partial thrombus in 5% of individuals. In conclusion, even though nerve dysfunction compromised shoulder abduction, vein dysfunction rarely resulted in any significant clinical impact.

A Familial Case Report of a 13;22 Chromosomal Translocation with Recurrent Intracytoplasmic Sperm Injection Failure.

The importance of cytogenetic analysis in a family with reproductive failure in two siblings is highlighted, where two siblings and their mother presented with a balanced translocation between chromosomes 13;22. The clinical evaluation had shown the female to be normal and the male to be oligoasthenoteratozoospermic despite repeated semen analysis. The couple was referred to our laboratory after three consecutive intracytoplasmic sperm injection (ICSI) failures at a local assisted reproductive technique (ART) center. Peripheral blood lymphocytes, obtained for karyotyping, were studied by a standard G-banding technique. Chromosomal analysis of the members of the pedigree, including the probands, showed the presence of the same translocation, t(13;22)(q21.2;q13.3), carried by three generations of the family. The sister and the mother of the proband had multiple spontaneous abortions in the first trimester. The spouses, when examined cytogenetically, were found to be normal. We propose the involvement of a balanced t(13;22)(q21.2;q13.3) chromosomal translocation in the pathogenesis of recurrent ART or spontaneous reproductive failures. Hence, it is suggested that all cases with structural chromosomal abnormalities be counseled prior to opting for ART and undergoing pre-implantation genetic diagnosis (PGD). This would prevent recurrent financial, physical and emotional stress in couples seeking ART.