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Background: Airway mucus plugs are frequently identified on CT scans of patients with COPD with a smoking history without mucus-related symptoms (ie, cough, phlegm [silent mucus plugs])., Research Question: In patients with COPD, what are the risk and protective factors associated with silent airway mucus plugs? Are silent mucus plugs associated with functional, structural, and clinical measures of disease?, Study Design and Methods: We identified mucus plugs on chest CT scans of participants with COPD from the COPDGene study. The mucus plug score was defined as the number of pulmonary segments with mucus plugs, ranging from 0 to 18, and categorized into three groups (0, 1-2, and ≥ 3). We determined risk and protective factors for silent mucus plugs and the associations of silent mucus plugs with measures of disease severity using multivariable linear and logistic regression models., Results: Of 4,363 participants with COPD, 1,739 had no cough or phlegm. Among the 1,739 participants, 627 (36%) had airway mucus plugs identified on CT scan. Risk factors of silent mucus plugs (compared with symptomatic mucus plugs) were older age (OR, 1.02), female sex (OR, 1.40), and Black race (OR, 1.93) (all P values < .01). Among those without cough or phlegm, silent mucus plugs (vs absence of mucus plugs) were associated with worse 6-min walk distance, worse resting arterial oxygen saturation, worse FEV 1 % predicted, greater emphysema, thicker airway walls, and higher odds of severe exacerbation in the past year in adjusted models., Interpretation: Mucus plugs are common in patients with COPD without mucus-related symptoms. Silent mucus plugs are associated with worse functional, structural, and clinical measures of disease. CT scan-identified mucus plugs can complement the evaluation of patients with COPD., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: M. H. C. reported receiving grants from Bayer. A. A. D. reported receiving personal fees from Boehringer-Ingelheim and having a patent for Methods and Compositions Relating to Airway Dysfunction pending (701586-190200USPT). N. L. T. reported that she and/or her husband are general stockholders with no controlling interest in the following: Johnson & Johnson, Kimberly-Clark Corp, Microsoft Corp, Amgen Inc, Bristol Myers Squibb, Cisco Systems Inc, Medtronic, Merck & Co Inc, Procter & Gamble, Crisper Therapeutics, Nvidia, Texas Instruments, Hewlett-Packard, United Health, Abbott Labs, Eli Lilly and Co, AbbVie Inc, and LyondellBasell Industries. Ruben S. J. Estépar reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Raúl S. J. Estépar reported being a founder and equity holder of Quantitative Imaging Solutions; receiving grants from Boehringer-Ingelheim; contracts to serve as image core from Insmed and Lung Biotechnology; and personal fees from LeukoLab and Chiesi. A. C. Y. is supported by the NIH [Grants R01HL149861, R01HL164824, U01HL089897]. None declared (S. K. M., H. P. N., S. G., J. L. O., W. R. D., P. N., S. J. K., K. J., P. P. M., M. A., M. U. A., M. Z., A. N. A., R. E., S. S., E. B., W. W., J. B. R.)., (Copyright © 2023 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Rationale/Objective: Acute exacerbations (AEs) of chronic obstructive pulmonary disease (COPD) are associated with significant morbidity and mortality. Whether mucus plugs are associated with prospective exacerbations has not been examined extensively., Methods: Mucus plugs were visually-identified on baseline chest computed tomography (CT) scans from smokers with Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades 2-4 COPD enrolled in two multicenter cohort studies: Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) and COPDGene. Associations between ordinal mucus plug score categories (0/1-2/≥3) and prospectively-ascertained AEs, defined as worsening respiratory symptoms requiring systemic steroids and/or antibiotics (moderate-to-severe) and/or ER/hospitalization (severe), were assessed using multivariable-adjusted zero-inflated Poisson regression; subjects were exacerbation-free at enrollment., Results: Among 3,250 participants in COPDGene (mean±SD age 63.7±8.4 years, FEV1 50.6%±17.8% predicted, 45.1% female) and 1,716 participants in ECLIPSE (age 63.3±7.1 years, FEV1 48.3%±15.8% predicted, 36.2% female), 44.4% and 46.0% had mucus plugs, respectively. The incidence rates of AEs were 61.0 (COPDGene) and 125.7 (ECLIPSE) per 100 person-years. Relative to those without mucus plugs, the presence of 1-2 and ≥3 mucus plugs was associated with increased risk (adjusted rate ratio, aRR [95%CI]=1.07[1.05-1.09] and 1.15[1.1-1.2] in COPDGene; aRR=1.06[1.02-1.09] and 1.12[1.04-1.2] in ECLIPSE, respectively) for prospective moderate-to-severe AEs. The presence of 1-2 and ≥3 mucus plugs was also associated with increased risk for severe AEs during follow-up (aRR=1.05[1.01-1.08] and 1.09[1.02-1.18] in COPDGene; aRR=1.17[1.07-1.27] and 1.37[1.15-1.62] in ECLIPSE, respectively)., Conclusion: CT-based mucus plugs are associated with an increased risk for future COPD AEs.

Radiologists across many imaging modalities commonly encounter gallbladder adenomyomatosis. The classic imaging appearances of gallbladder adenomyomatosis are well described and confirm benignity. However, in clinical practice, adenomyomatosis can be challenging to differentiate from other gallbladder pathologies that require cholecystectomy. In this article, we describe the common and uncommon appearances of gallbladder adenomyomatosis on multimodality imaging, helping differentiate adenomyomatosis from non-benign gallbladder abnormalities. Accurately differentiating adenomyomatosis from its mimics provides the surgical team with important clinical and surgical management information, improving patient outcomes., Competing Interests: Declaration of competing interest There are no financial or personal interests to report on behalf of all authors regarding this publication., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Patients with kidney failure require kidney replacement therapy. While renal transplantation remains the treatment of choice for kidney failure, renal replacement therapy with hemodialysis may be required owing to the limited availability and length of time patients may wait for allografts or for patients ineligible for transplant owing to advanced age or comorbidities. The ideal hemodialysis access should provide complication-free dialysis by creating a direct connection between an artery and vein with adequate blood flow that can be reliably and easily accessed percutaneously several times a week. Surgical arteriovenous fistulas and grafts are commonly created for hemodialysis access, with newer techniques that involve the use of minimally invasive endovascular approaches. The emphasis on proactive planning for the placement, protection, and preservation of the next vascular access before the current one fails has increased the use of US for preoperative mapping and monitoring of complications for potential interventions. Preoperative US of the extremity vasculature helps assess anatomic suitability before vascular access creation, increasing the rates of successful maturation. A US mapping protocol ensures reliable measurements and clear communication of anatomic variants that may alter surgical planning. Postoperative imaging helps assess fistula maturation before cannulation for dialysis and evaluates for early and late complications associated with arteriovenous access. Clinical and US findings can suggest developing stenosis that may progress to thrombosis and loss of access function, which can be treated with percutaneous vascular interventions to preserve access patency. Vascular access steal, aneurysms and pseudoaneurysms, and fluid collections are other complications amenable to US evaluation. © RSNA, 2023 Supplemental material is available for this article. Test Your Knowledge questions for this article are available through the Online Learning Center.

Importance: Airway mucus plugs are common in patients with chronic obstructive pulmonary disease (COPD); however, the association of airway mucus plugging and mortality in patients with COPD is unknown., Objective: To determine whether airway mucus plugs identified on chest computed tomography (CT) were associated with increased all-cause mortality., Design, Setting, and Participants: Observational retrospective analysis of prospectively collected data of patients with a diagnosis of COPD in the Genetic Epidemiology of COPD cohort. Participants were non-Hispanic Black or White individuals, aged 45 to 80 years, who smoked at least 10 pack-years. Participants were enrolled at 21 centers across the US between November 2007 and April 2011 and were followed up through August 31, 2022., Exposures: Mucus plugs that completely occluded airways on chest CT scans, identified in medium- to large-sized airways (ie, approximately 2- to 10-mm lumen diameter) and categorized as affecting 0, 1 to 2, or 3 or more lung segments., Main Outcomes and Measures: The primary outcome was all-cause mortality, assessed with proportional hazard regression analysis. Models were adjusted for age, sex, race and ethnicity, body mass index, pack-years smoked, current smoking status, forced expiratory volume in the first second of expiration, and CT measures of emphysema and airway disease., Results: Among the 4483 participants with COPD, 4363 were included in the primary analysis (median age, 63 years [IQR, 57-70 years]; 44% were women). A total of 2585 (59.3%), 953 (21.8%), and 825 (18.9%) participants had mucus plugs in 0, 1 to 2, and 3 or more lung segments, respectively. During a median 9.5-year follow-up, 1769 participants (40.6%) died. The mortality rates were 34.0% (95% CI, 32.2%-35.8%), 46.7% (95% CI, 43.5%-49.9%), and 54.1% (95% CI, 50.7%-57.4%) in participants who had mucus plugs in 0, 1 to 2, and 3 or more lung segments, respectively. The presence of mucus plugs in 1 to 2 vs 0 and 3 or more vs 0 lung segments was associated with an adjusted hazard ratio of death of 1.15 (95% CI, 1.02-1.29) and 1.24 (95% CI, 1.10-1.41), respectively., Conclusions and Relevance: In participants with COPD, the presence of mucus plugs that obstructed medium- to large-sized airways was associated with higher all-cause mortality compared with patients without mucus plugging on chest CT scans.

Background and purpose Liver cirrhosis is common, and timely diagnosis of decompensated cirrhosis may impact acute care and resuscitation. Point-of-care ultrasound is a core competency of US emergency medicine training and is increasingly available in many acute care settings, including those where usual diagnostic modalities of cirrhosis may not be available. Only a few works of literature exist that evaluate the ultrasound diagnosis of cirrhosis and decompensated cirrhosis by emergency physicians (EPs). We aim to evaluate whether EPs can diagnose cirrhosis by ultrasound after a brief educational intervention and determine the accuracy of EP-interpreted ultrasound compared to the radiology-interpreted ultrasound as a gold standard. Methods This single-center prospective single-arm educational intervention evaluated the accuracy of EPs diagnosing cirrhosis and decompensated cirrhosis on ultrasound before and after a short educational intervention. Responses were paired across the three assessments, and paired sample t-tests were performed. Sensitivity, specificity, and likelihood ratios were calculated using attending radiology-interpreted ultrasounds as the gold standard. Results EPs scored a mean of 16% higher on a delayed knowledge assessment one month after the educational intervention than on the pre-intervention assessment. EP-interpreted ultrasound revealed a sensitivity of 0.90, specificity of 0.71, positive likelihood ratio of 3.08, and negative likelihood ratio of 0.14 compared to radiology-interpreted ultrasound. The sensitivity of our cohort was 0.98 for decompensated cirrhosis. Conclusions After a brief educational intervention, EPs can significantly increase their sensitivity and specificity in diagnosing cirrhosis using ultrasound. EPs were particularly sensitive in their diagnosis of decompensated cirrhosis., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Kilgore et al.)

Male genitourinary neuroendocrine neoplasms (GU-NENs) are rare, without any definite imaging characteristics. The WHO classified neuroendocrine neoplasms in the 2016 classification of the tumors of the urinary tract and genital organs along with other GU tumors; however, no pathologic grading system is available as published for gastroenteropancreatic neuroendocrine neoplasms. Often a multimodality approach using cross-sectional imaging techniques, such as molecular imaging and histopathology are implemented to arrive at the diagnosis. This article provides a review of the pathology and imaging features of the male GU-NENs., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Vascular imaging with color and power Doppler is a useful tool in the assessment of various disease processes. Assessment of blood flow, from infarction and ischemia to hyperemia, in organs, neoplasms, and vessels, is used in nearly every US investigation. Recent developments in this area are sensitive to small-vessel low velocity flow without use of intravenous contrast agents, known as microvascular flow imaging (MVFI). MVFI is more sensitive in detection of small vessels than color, power, and spectral Doppler, reducing the need for follow-up contrast-enhanced US (CEUS), CT, and MRI, except when arterial and venous wash-in and washout characteristics would be helpful in diagnosis. Varying clinical applications of MVFI are reviewed in adult and pediatric populations, including its technical underpinnings. MVFI shows promise in assessment of several conditions including benign and malignant lesions in the liver and kidney, acute pathologic abnormalities in the gallbladder and testes, and superficial lymph nodes. Future potential of MVFI in different conditions (eg, endovascular repair) is discussed. Finally, clinical cases in which MVFI correlated and potentially obviated additional CEUS, CT, or MRI are shown., (© RSNA, 2022.)

Rationale and Objectives: To date, no clinically useful classification system has been developed for reliably differentiating mucinous cystic neoplasm (MCN) from a benign hepatic cyst (BHC) in the liver. The objective was to use machine learning and a multi-center study design to develop and assess the performance of a novel classification system for predicting whether a hepatic cystic lesion represents MCN or BHC., Materials and Methods: A multi-center cohort study identified 154 surgically resected hepatic cystic lesions in 154 subjects which were pathologic confirmed as MCN (43) or BHC (111). Readers at each institution recorded seven pre-determined imaging features previously identified as potential differentiating features from prior publications. The contribution of each of these features to differentiating MCN from BHC was assessed by machine learning to develop an optimal classification system., Results: Although several of the assessed imaging features demonstrated statistical significance, only 3 imaging features were found by machine learning to significantly contribute to a potential classification system: (1) solid enhancing nodule (2) all septations arising from an external macro-lobulation (3) whether the lesion was solitary or one of multiple cystic liver lesions. The optimal classification system had only four categories and correctly identified 144/154 lesion (93.5%)., Conclusion: This multi-center follow-up study was able to use machine learning to develop a highly accurate classification system for differentiation of hepatic MCN from BHC, which could be readily applied to clinical practice., (Copyright © 2021 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Lead (Pb) is found in almost all phases in environment and biological systems. Pb stimulated oxidative stress is a state that involves the generation of free radicals beyond the permissible limits, which can deplete the antioxidant reserves and can result in oxidative stress, thus hampering the ability of the biological system to reverse the result. Exposure of rats to Pb (25 mg/kg body weight) for 8 weeks caused an increase in Pb levels in blood and brain. Activity of delta-aminolevulinic acid dehydratase (δ-ALAD) and antioxidant enzymes such as Superoxide dismutase (SOD) and Catalase (CAT) decreased in the blood of Pb-treated group with a concomitant increase in the level of lipid peroxidation (LPO) and no significant change in the level of reduced glutathione (GSH) level was found. Interestingly, co-treatment of Pb-treated rats with curcumin (30 mg/kg body weight) and quercetin (30 mg/kg body weight) for 8 weeks caused a significant decrease in Pb levels of blood and all brain regions versus those treated with Pb alone. A significant improvement in levels of MDA, δ-ALAD, SOD and CAT activities was observed in rats simultaneously treated with curcumin or Quercetin or both with lead. Therefore, the ameliorative impact of curcumin and Quercetin might be due to their antioxidant property hence were able to counter the oxidative stress generated by Pb. These results suggest that combination of curcumin and Quercetin could be utilized as a possible supplement with the relevant therapeutics in the suitable management of Pb toxicity., Competing Interests: Conflicts of interestThe authors declare that they have no conflict of interest., (© Association of Clinical Biochemists of India 2021.)

Fibropolycystic liver diseases (FLDs) make up a rare spectrum of heritable hepatobiliary diseases resulting from congenital ductal plate malformations (DPMs) due to the dysfunction of proteins expressed on the primary cilia of cholangiocytes. The embryonic development of the ductal plate is key to understanding this spectrum of diseases. In particular, DPMs can result in various degrees of intrahepatic duct involvement and a wide spectrum of cholangiopathies, including congenital hepatic fibrosis, Caroli disease, polycystic liver disease, and Von Meyenberg complexes. The most common clinical manifestations of FLDs are portal hypertension, cholestasis, cholangitis, and (in rare cases) cholangiocarcinoma. This article reviews recent updates in the pathophysiology, imaging, and clinical management of FLDs., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Cardiac arrhythmia is a leading cause of cardiovascular disease, with a high fatality rate worldwide. The timely diagnosis of cardiac arrhythmias, determined by irregular and fast heart rate, may help lower the risk of strokes. Electrocardiogram signals have been widely used to identify arrhythmias due to their non-invasive approach. However, the manual process is error-prone and time-consuming. A better alternative is to utilize deep learning models for early automatic identification of cardiac arrhythmia, thereby enhancing diagnosis and treatment. In this article, a novel deep learning model, combining convolutional neural network and bi-directional long short-term memory, is proposed for arrhythmia classification. Specifically, the classification comprises five different classes: non-ectopic (N), supraventricular ectopic (S), ventricular ectopic (V), fusion (F), and unknown (Q) beats. The proposed model is trained, validated, and tested using MIT-BIH and St-Petersburg data sets separately. Also, the performance was measured in terms of precision, accuracy, recall, specificity, and f1-score. The results show that the proposed model achieves training, validation, and testing accuracies of 100%, 98%, and 98%, respectively with the MIT-BIH data set. Lower accuracies were shown for the St-Petersburg data set. The performance of the proposed model based on the MIT-BIH data set is also compared with the performance of existing models based on the MIT-BIH data set., Competing Interests: Declaration of conflicting interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Background: Lead (Pb) is a worldwide concern due to its persistent property in the environment. However, due to diminutive evidence and elusiveness, the impact of lead exposure on the biochemical and haematological parameter in school-age children is not well established., Aim: This study primarily aimed to investigate blood lead (BL) in children and its association with haematological and biochemical parameter., Methods: A total of 43 children (4-12 years) were recruited in each control and study group. Furthermore, the study group were subdivided into two groups (group A (<10 μg/dl) and group B (>10 μg/dl)). BL level, haematological parameter including haemoglobin, packed cell volume, red blood cells, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, total leukocytes count, neutrophils, lymphocytes, monocytes, mean corpuscular volume, red cell distribution width, eosinophil's, platelets in the whole blood and biochemical parameter such as liver function test (total bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, total protein, albumin) and kidney function test (sodium, potassium, blood urea nitrogen, creatinine) in serum were measured using anodic stripping voltammeter (ASV), Cell-Dyn Ruby Haematology analyser, Beckman coulter Unicel Dxc 800 Synchron Clinical analyser respectively., Results: The arithmetical mean of BL level was 19.93 ± 9.22 μg/dl (median: 17.5 μg/dl; range 9.1-37.4 μg/dl). Only 21 % children had BL levels <10 μg/dl and there were 79 % children with BL levels >10 μg/dl. Blood mean corpuscular haemoglobin concentration, Neutrophils, Monocytes were significantly higher between the control and study group. Additionally, haemoglobin, packed cell volume, red blood cells, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, Lymphocytes and mean corpuscular volume intensities were significantly lower in >10 μg/dl group whereas total leukocytes count, neutrophils, monocytes, red cell distribution width, eosinophil's, platelets levels were statistically higher (p < 0.001). Serum alkaline phosphatase, serum glutamic-oxaloacetic transaminase, total protein, were higher (p < 0.05) and sodium, albumin were significantly lower in the study group. The mean value of sodium, potassium, total bilirubin, alkaline phosphatase, serum glutamic-pyruvic transaminase, total protein and blood urea nitrogen, creatinine in two groups (<10 μg/dl and >10 μg/dl) was not significantly different. Serum glutamic-oxaloacetic transaminase level was significantly higher (p = 0.015) while albumin levels were significantly lower (p = 0.034) in >10 μg/dl group. A statistically significant correlation of BL levels with all haematological parameters was also observed. Creatinine is positively and albumin was negatively correlated with BL levels., Conclusion: The outcomes specify that high BL levels were significantly associated with higher haematological and biochemical indices in exposed children. However, lead like noxious metals severely affected the haematological, kidney and liver health of children., (Copyright © 2021 Elsevier GmbH. All rights reserved.)

Palm oil mill effluent (POME) is highly polluted wastewater that is to the environment if discharged directly to water source without proper treatment. Thus, a highly efficient treatment with reasonable cost is needed. This study reports the coagulation treatment of POME using integrated copperas and calcium hydroxide. The properties of copperas were determined using scanning electron microscopy (SEM), Fourier transform infrared (FTIR), X-ray diffraction (XRD), and X-ray fluorescence (XRF). Coagulation was conducted using jar test experiments for various coagulant formulations and dosages (1000-5000 mg/L), initial pH (4-10), stirring speed (100-300 rpm), and sedimentation time (30-180 min). The characterisation results show that copperas has a compact gel network structure with strong O-H stretching and monoclinic crystal structure. The effectiveness of integrated copperas and calcium hydroxide (Ca(OH) 2 ) with the formulation of 80:20 removed 77.6%, 73.4%, and 57.0% of turbidity, colour, and chemical oxygen demand (COD), respectively. Furthermore, the integration of copperas and Ca(OH) 2 produced heavier flocs (ferric hydroxide), which improved gravity settling. The coagulation equilibrium analysis shows that the Langmuir model best described the anaerobic POME sample as the process exhibited monolayer adsorption. The results of this study show that copperas with the aid of Ca(OH) 2 demonstrated high potential in the removal of those parameters from POME with acceptable final pH for discharge. The utilisation of this by-product as a coagulant in effluent treatment can unlock the potential of copperas for wider applications, improve its marketability, and reduce gypsum waste generation from the TiO 2 industry., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

In this review article, we will discuss the gamut of abnormalities involving the ureters. In the emergency department, ureterolithiasis is the most common indication for imaging abdomen and pelvis. However, spectrum of ureteral abnormalities including congenital, infectious and inflammatory, primary and secondary ureteral malignancies, retroperitoneal fibrosis rare described in this article may be encountered. Thus, we will describe acute subacute as well as chronic conditions that may affect ureter. Knowledge of common, as well as rare entities and their imaging features, is of utmost importance to enable appropriate management., (© 2021. American Society of Emergency Radiology.)

This is a review article on cross-sectional imaging spectrum of abdominal and pelvic vascular compression syndromes in emergency settings, discussing about pathophysiology, clinical presentation, imaging findings, and appropriate management of such entities. It is important to understand the overlap of imaging findings with common anatomic variations. Equally, the subtle imaging features of abdominal vascular compression syndrome may be equivocal for interpreting radiologist. Early recognition is important, in order to refer patients for appropriate treatment. Cross-sectional imaging with computed tomography (CT) and magnetic resonance imaging (MRI) is usually performed to detect such abdominal vascular compression syndromes. For comprehensive review, the utility of color Doppler in evaluation and diagnosis is also emphasized in each section. Percutaneous angiography is usually considered as a reference standard for the diagnosis but limited due to its invasive nature. Surgical and endovascular management of these vascular compression syndromes is briefly described.

Background: Vitamin D deficiency (VDD) is seen in all races, age groups, and ethnic backgrounds. VDD estimated to affect >1 billion people worldwide. The purpose of the present study is to characterize the extent of Vitamin D inadequacy and parathyroid hormone (PTH) levels among patients presenting to us for fracture management., Materials and Methods: A prospective case-control study was performed whereby serum Vitamin D levels and corresponding PTH levels were measured. The study subjects included patients >45 years of age irrespective of sex who presented with fracture as a result of trivial trauma. A total of 102 cases (34 intertrochanteric fracture, 66 fracture neck of femur, and 2 Colle's fracture) and 100 controls were included in the study., Result: Average serum hydroxy-vitamin D and serum PTH of cases 15.8 ± 5.25 ng/mL and 91.15 ± 6.03 pg/mL, respectively. Average S.25-OH Vitamin D and serum PTH of controls was 25.49 ± 3.79 ng/mL and 23.46 ± 3.79 pg/mL, respectively. Eighty (78.4%) cases were in insufficient range (Vitamin D between 10-30 ng/mL), 16 (15.6%) were deficient (Vitamin D <10 ng/mL), and only 6 (5.8%) were sufficient (Vitamin D >30 ng/mL). While in controls, 28% had sufficient and 72% had insufficient Vitamin D levels. There was no deficient control. Serum PTH levels were significantly raised in cases when compared to controls consistent with secondary hyperparathyroidism., Conclusion: This study gives us very important data regarding the prevalence of VDD and rise of PTH secondary to the former and this hormonal milieu in our body is an independent risk factor for increased incidence of fracture., Competing Interests: There are no conflicts of interest.

Closed degloving skin lesions of the limbs are uncommon, and diagnosis may be missed at the time of acute trauma. Usually, they are associated with pelvic fractures but may occur in absence of any bony injury. When this closed internal degloving occurs over the greater trochanter, it is known as a Morel-Lavallee lesion. We report a case of unusually delayed presentation of Morel-Lavallee lesion treated successfully by debridement, packing, and delayed closure.

Volar carpometacarpal dislocation is a rare form of hand injury that can be easily missed without applying a high level of suspicion and performing a meticulous examination. In this case report, we present a rare case of compound volar dislocation of the second, third, and fourth carpometacarpal joints in a 40-year-old male. This was managed by closed reduction and the use of a mini external fixator. The patient regained a good range of motion in 6 weeks with no pain. It is important to diagnose and treat this injury in order to avoid the considerable morbidity associated with this condition.

Vertebra plana is a rare presentation of spinal lymphoma. When radiological picture of a patient of paraplegia presents vertebra plana, diagnosis becomes a challenge. In a developing country like India tuberculosis should also be a consideration. Even histology sometimes fails to conclude a diagnosis. Immunohistochemistry is of immense help in clinching a diagnosis.

Synchronous primary intracranial germ cell tumors are rare. Only 5-10% of all germ cell tumors are found as synchronous lesion in pineal and suprasellar region. They are also known by the entity "double mid-line atypical teratoma". An 11-year-old male child presented with polyuria, polydipsia and features of raised intracranial tension. CT scan head revealed well-defined homogenously enhancing lesions in the pineal and suprasellar region. Histopathology examination showed the lesion to be of germ cell origin.

A prospective observational study was conducted at J. N. Medical College, Aligarh Muslim University, to compare the bacterial flora obtained from sequestrum culture and sinus track culture and to evaluate their antibiotic sensitivity. A total of 62 patients with chronic osteomyelitis were enrolled (38 males and 24 females). Sinus track cultures were done taking all aseptic precautions and the results were compared. Thirty three patients out of 62 showed a discrepancy between the bacterial flora grown from sinus track and sequestrum cultures.

A rare case of tuberculosis of the stemoclavicular joint in a 13-year-old girl is presented. The occurrence of tubercular infection in the sternoclavicular joint is extremely rare.