Nonunion of an Isolated Medial Condyle of a Femur Hoffa Fracture in a 21-Year-Old Male: A Case Report.

Isolated Hoffa fractures of the femur are often missed on initial radiographic evaluations. Routine CT scans for intraarticular fractures in suburban populations are not routinely done. Nonunion of medial condyle Hoffa fracture of the distal femur is a rare finding and presents late with pain in weight-bearing and painful flexion. This is a case report of a 21-year-old male who sustained trauma as a result of a motorcycle-car collision and was managed elsewhere conservatively on an above-knee slab. He presented after five months to our side with a limited range of movement at the knee and pain during ambulation. After radiological work diagnosis of isolated non-union of medal condyle Hoffa fracture of the distal femur was made, the patient was managed by freshening of fracture followed by rigid fixation with cancellous screws and reconstruction plate. At postoperative six weeks, the patient had a painless full range of motion at the knee joint.

Limb Salvage Strategy Amendment for a Better Future in the Era of Bone Cancer Therapy: A Cross-Sectional Study in North India.

BACKGROUND:  Bone tumors remain a formidable challenge for orthopedic surgeons. In developing countries, the challenge is exacerbated by limited diagnostic, therapeutic, and management facilities and ignorance. Patients with upper and lower-extremity muscle and skeletal tumors are candidates for amputation or surgical rescue of the limbs. Traditionally, limb rescue surgery by neo-adjuvant chemotherapy is the preferred surgery method for localized carcinoma. Amputations are usually reserved for patients with increased tumor size. The purpose of this study is to investigate health-related quality of life (HRQOL) and physical disability, focusing on surgical care, gender, and age, in adolescent and young adult survivors of malignant bone tumors treated surgically. METHODS:  This cross-sectional study consists of 38 long-term survivors who underwent amputation or limb-salvage surgery at King George's Medical University, Lucknow, from 2019 to 2022. After obtaining ethical clearance and informed consent, 38 patients which included 26 patients treated with limb salvage in Group A and 12 patients treated with amputation in Group B were included in the study. The SF-36 and HUI3 scores were used to assess the functional outcome and health-related QoL of these patients. RESULTS:  After minimal six months of interventions, we have found a significant improvement in all the following factors: physical functioning (P=0.000), role limitations due to physical health (P=0.000) and emotional problems (P=0.001), energy/fatigue (P=0.000), emotional well-being (P=0.000), social functioning (P=0.000), pain (P=0.000), and general health (P=0.000). Group A showed a higher degree of significance than Group B through SF-36 (Short Form-36, patient-reported outcome), whereas HUI-3 did not show any significant outcomes (P=0.347). CONCLUSION:  The overall quality of life of patients with salvaged limbs appears to be higher than that of the quality of life of amputee patients in tumor survivor patients. Further analyses must be carried out to verify the results and focus on areas that have a major impact on the overall quality of life using other assessment tools. The impact of therapy on the quality of life depends on maintaining the necessary structures for functional functions, adjusting patient expectations to cancer treatments, and designing long-term rehabilitation programs to support functional functions.

Local Versus Systemic Tranexamic Acid in Total Hip Arthroplasty in Young Adults.

Background Total hip arthroplasty (THA) is the most successful orthopedic elective surgical procedure for end-stage hip arthritis. THA is linked with significant blood loss, ranging from 1,188 to 1,651 mL, and a transfusion rate of 16-37%, which frequently results in postoperative blood transfusions. Postoperative blood transfusions can be avoided by using autologous blood transfusion, intraoperative blood saving, local anesthetic, hypotensive anesthesia, and antifibrinolytic medications such as tranexamic acid (TXA) administration. Methodology A double-blinded, placebo-controlled, randomized, controlled study was conducted with three prospective groups to investigate the efficacy of topical and systemic routes of a single intraoperative dose (1.5 g) of TXA. Patients were recruited from our center between October 2021 to March 2022 who were undergoing primary total hip replacement. Estimated blood loss was calculated and compared in groups, and a p-value of <0.05 was taken as significant. Results A total of 60 patients were recruited in our study. Estimated blood loss was similar in both treatment groups, 816.8 ± 219.9 mL in the systemic TXA group and 775.5 ± 107.2 mL in the topical TXA group. The placebo group had 1,066.3 ± 150.4 mL estimated blood loss, which was significantly higher compared to the treatment groups. Conclusions Administration of TXA (1.5 g) significantly lowers blood loss without increasing problems, which can eliminate concerns about intravenous TXA use. TXA reduces blood loss by 270 mL on average.

RADHunters: gamification in radiology perceptual education.

Purpose: Gamification is used in several fields as an adjunct to standard educational methods but has found limited application in radiology to date. Gamification may be useful for teaching radiology skills typically acquired through experience, such as perceptual skills. The goal of our study is to use a gamified radiology workstation to teach skills related to identification of pulmonary nodules and evaluate for changes in trainee performance. Approach: We constructed a game called RADHunters to teach perceptual skills related to identification of pulmonary nodules on chest radiographs. Control and experimental groups were tasked with identifying nodules on chest radiographs on two sets of cases. The experimental group received gamified training for nodule identification using RADHunters between case sets, while the control group did not. Performance at nodule identification, localization, and confidence were compared. A poststudy survey was administered to assess for participants' thoughts about the gamified nodule detection training. Results: Survey responses were very positive with p -values for all survey responses < 0.001 , indicating subjects felt this training was beneficial. Experimental and control groups had a statistically significant improvement in their ability to identify and localize nodules with p -values < 0.05 . There was no significant difference between control and experimental groups. Neither group showed a statistically significant increase in their confidence in nodule localization. Conclusions: Perceptual training using gamification may be a useful adjunct to conventional methods of radiology education.

An Unusual Pulmonary Aspergillus Infection: Endobronchial Aspergilloma.

Endobronchial aspergilloma (EBA) is an extremely rare presentation of pulmonary involvement of Aspergillus. It is a noninvasive form of pulmonary aspergillosis where the fungus overgrows and colonizes the bronchial lumen. The patient may present with chronic cough, dyspnea, hemoptysis, or wheezing. The diagnosis is usually incidental when bronchoscopy is performed to evaluate the cause of hemoptysis or radiological abnormalities. Here, we report a case of a middle-aged female who presented with hemoptysis and right middle lobe collapse and was subsequently diagnosed to have EBA on bronchoscopy with endobronchial biopsy. Although EBA is rare, it should be considered as a differential in the evaluation of endobronchial mass lesions.

Effectiveness of four ultrasonographic parameters as predictors of difficult intubation in patients without anticipated difficult airway.

BACKGROUND: Predicting difficult intubation (DI) is a key challenge, as no single clinical predictor is sufficiently valid to predict the outcome. We evaluated the effectiveness of four upper airway ultrasonographic parameters in predicting DI. The validity of the models using combinations of ultrasonography-based parameters was also investigated. METHODS: This prospective, observational, double-blinded cohort trial enrolled 1,043 surgical patients classified as American Society of Anesthesiologists physical status I-III without anticipated difficult airway. Preoperatively, their tongue thickness (TT), invisibility of hyoid bone (VH), and anterior neck soft tissue thickness from the skin to thyrohyoid membrane (ST) and hyoid bone (SH) were measured by sublingual and submandibular ultrasonography. The logistic regression, Youden index, and receiver operator characteristic analysis results were reported. RESULTS: Overall, 58 (5.6%) patients were classified as DI. The TT, SH, ST, and VH had accuracies of 78.4%, 85.0%, 84.7%, and 84.9%, respectively. The optimal values of TT, SH, and ST for predicting DI were > 5.8 cm (sensitivity: 84.5%, specificity: 78.1%, AUC: 0.880), > 1.4 cm (sensitivity: 81%, specificity: 85.2%, AUC: 0.898) and > 2.4 cm (sensitivity: 75.9%, specificity: 85.2%, AUC: 0.885) respectively. VH had a sensitivity and specificity of 72.4% and 85.6% (AUC: 0.790). The AUC values of the five models (with combinations of three or four parameters) ranged from 0.975-0.992. ST and VH had a significant impact on the individual models. CONCLUSIONS: SH had the best accuracy. Individual parameters showed limited validity. The model including all four parameters offered the best diagnostic value.

Coxsackie Myocarditis with Severe Methicillin-resistant Staphylococcus aureus Sepsis, Multi-organ Dysfunction Syndrome, and Posterior Epidural Spinal Abscess: A Case Report.

AIM: The aim of this paper is to present an interesting case of viral myocarditis complicated by sepsis, its sequelae, including multi-organ dysfunction syndrome, and the approach to manage it successfully. BACKGROUND: Viral myocarditis is an inflammatory disease of myocardium, often leading to residual heart disease. Commonly, dengue and Coxsackie B viruses are the causative agents. Patients usually present with dyspnea, fever, and signs of heart failure. A possibility of bacterial sepsis should not be overlooked, given similar presentations may occur. CASE DESCRIPTION: A 21-year-old male presented with acute onset breathlessness, fever, chills, and severe neck pain. On a detailed workup, he was found to have features suggestive of viral myocarditis, bacterial sepsis, with bilateral pleural loculations, a posterior epidural spinal abscess. Elimination of infectious foci, along with a decision to stick to the ongoing antibiotics, instead of stepping up to the last available ones proved beneficial. Meticulous balance of diuretics and inotropes saved the patient's life from what turned out to be coxsackie myocarditis. CONCLUSION: Here, we present the case of a young male who came in with congestive heart failure due to Coxsackie myocarditis and his condition complicated by severe sepsis. CLINICAL SIGNIFICANCE: Up to 10% of the cases of coxsackie myocarditis progress to chronic dilated cardiomyopathy. The management is usually conservative, and antiviral agents have shown no role in speedy recovery. Elimination of infectious foci aggressively is of prime importance in the treatment of bacterial sepsis. A careful balance of inotropes, diuretics, and fluid management is needed to get the patient into remission in such cases. HOW TO CITE THIS ARTICLE: Morkar DN, Agarwal R, Patil RS. Coxsackie Myocarditis with Severe Methicillin-resistant Staphylococcus aureus Sepsis, Multi-organ Dysfunction Syndrome, and Posterior Epidural Spinal Abscess: A Case Report. Indian J Crit Care Med 2020;24(1):73-76.

Glycation alters the mechanical behavior of kidney extracellular matrix.

The mechanical properties of the extracellular matrix (ECM) are important in maintaining normal physiological function, and changes in ECM mechanics drive disease. The biochemical structure of the ECM is modified with aging and in diseases such as diabetes. One mechanism of ECM modification is the non-enzymatic reaction between sugars and ECM proteins resulting in formation of advanced glycation end products (AGEs). Some AGE reactions result in formation of molecular crosslinks within or between matrix proteins, but it is not clear how sugar-mediated biochemical modification of the ECM translates to changes in kidney ECM mechanical properties. AGE-mediated changes in ECM mechanics may have pathological consequences in diabetic kidney disease. To determine how sugars alter the mechanical properties of the kidney ECM, we employ custom methodologies to evaluate the mechanical properties of isolated tubular basement membrane (TBM) and glomerular ECM. Results show that the mechanical properties of TBM and glomerular ECM stiffness were altered by incubation in glucose and ribose. Mechanical behavior of TBM and glomerular ECM were further evaluated using mechanical models for hyperelastic materials in tension and compression. Increased ECM stiffness following sugar modification corresponded to increased crosslinking as determined by ECM fluorescence and reduced pepsin extractability of sugar modified ECM. These results show that sugar-induced modifications significantly affect the mechanical properties of kidney ECM. AGE-mediated changes in ECM mechanics may be important in progression of chronic diseases including diabetic kidney disease.

Ventriculoperitoneal shunt catheter migration in a patient with breast implants resulting in a peri-implant cerebrospinal fluid pseudocyst.

Ventriculoperitoneal (VP) shunts complications are most often divided into 2 broad categories: mechanical failure and infection. We report a case of a migrated VP shunt with subsequent development of a pseudocyst around the patient's breast implant, a rare complication. We review the literature of VP shunt complications, including the increasing number of reported breast-related complications, and discuss proposed mechanisms by which migration may occur. With the increase in patients with breast augmentation procedures, there is potential for an increase in the number of reported cases of VP shunt migration.

Delivery and tracking of quantum dot peptide bioconjugates in an intact developing avian brain.

Luminescent semiconductor ∼9.5 nm nanoparticles (quantum dots: QDs) have intrinsic physiochemical and optical properties which enable us to begin to understand the mechanisms of nanoparticle mediated chemical/drug delivery. Here, we demonstrate the ability of CdSe/ZnS core/shell QDs surface functionalized with a zwitterionic compact ligand to deliver a cell-penetrating lipopeptide to the developing chick embryo brain without any apparent toxicity. Functionalized QDs were conjugated to the palmitoylated peptide WGDap(Palmitoyl)VKIKKP9GGH6, previously shown to uniquely facilitate endosomal escape, and microinjected into the embryonic chick spinal cord canal at embryo day 4 (E4). We were subsequently able to follow the labeling of spinal cord extension into the ventricles, migratory neuroblasts, maturing brain cells, and complex structures such as the choroid plexus. QD intensity extended throughout the brain, and peaked between E8 and E11 when fluorescence was concentrated in the choroid plexus before declining to hatching (E21/P0). We observed no abnormalities in embryonic patterning or embryo survival, and mRNA in situ hybridization confirmed that, at key developmental stages, the expression pattern of genes associated with different brain cell types (brain lipid binding protein, Sox-2, proteolipid protein and Class III-ß-Tubulin) all showed a normal labeling pattern and intensity. Our findings suggest that we can use chemically modified QDs to identify and track neural stem cells as they migrate, that the choroid plexus clears these injected QDs/nanoparticles from the brain after E15, and that they can deliver drugs and peptides to the developing brain.