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The treatment of children with short stature was revolutionized by the creation of recombinant growth hormone therapy. While it cannot be denied that therapy adds significant height to children who are growth hormone deficient, such treatment is both painful, requiring many injections for years, as well as extremely expensive, both for the children's parents as well as for medical health care for society. With the indications for growth hormone treatment expanding over the years to include children with short stature who are not growth hormone deficient, it is important to determine all potential benefits beyond the obvious physical effects in order to make efficient cost-benefit determinations on appropriate usage of growth hormone therapy. One aspect of possible benefits for these children with short stature may be psychological features, such as increased overall happiness and self-esteem that is gained with increased height. A review and analysis of literature was undertaken in order to determine what effect, if any, growth hormone therapy has on short children's psychosocial well-being. [ABSTRACT FROM AUTHOR]

Due to the lower proportion of organic matter and higher toxicity of the aged landfill, most of the advanced treatment technologies are not effective from economic, environmental, and social perspectives. This study evaluates the potential of sulfate-reducing bacteria (SRB) based bioelectrochemical-system (BES) in the decontamination of landfill wastes by reducing GHGs emissions and levels of soluble pollutants. The landfill waste (solid/leachate) collected from the Pirana Landfill site was assessed for economical long-term treatment and scaling up the feasibility of the designed system. The present system demonstrated significant improvement in volumetric hydrogen production of 3.1:1 (H 2 :CH 4 ) by suppressing methanogenesis with a significant reduction in heavy metals concentration and other organic components. Despite being amended with 0.1 N ammonia, the treated leachate level of NO 3 (2.350 ± 1.077 mg/L) was reduced by 5.3 times, hence reducing further groundwater pollution from landfill leaching. The BES-treated solid waste was more stabilized as shown by a fivefold increase in surface area and can be potentially applied for leachate immobilization and bio-fortification of agricultural fields. The vector arrangement and magnitude with differences in magnitudes for both leachate and solid waste supported the on-site applicability of BES treatment. Concerning the affinity in various treatment systems, the dendrogram clearly showed Ca and Fe placed far from each other (3506.08), in comparison to Fe and Mg (1186.6), followed by Fe and Cu (1544.6). Voltammograms proved the efficacy of the enriched electrochemically active bacteria (EAB), to support the treatment of landfill solid waste and leachate sustainably., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Following medical school, most newly graduated physicians enter residency training. This period of graduate medical education (GME) is critical to creating a physician workforce with the specialized skills needed to care for the population. Completing GME training is also a requirement for obtaining medical licensure in all 50 states. Yet, crucial federal and state funding for GME is capped, creating a bottleneck in training an adequate physician workforce to meet future patient care needs. Thus, additional GME funding is needed to train more physicians. When considering this additional GME funding, it is imperative to take into account not only the future physician workforce but also the value added by residents to teaching hospitals and communities during their training. Residents positively affect patient care and health care delivery, providing intrinsic and often unmeasured value to patients, the hospital, the local community, the research enterprise, and undergraduate medical education. This added value is often overlooked in decisions regarding GME funding allocation. In this article, the authors underscore the value provided by residents to their training institutions and communities, with a focus on current and recent events, including the global COVID-19 pandemic and teaching hospital closures., (Copyright © 2022 by the Association of American Medical Colleges.)

Background: Simulation training in surgery is widespread and allows surgeons to practise novel operative techniques and acquaint themselves with unfamiliar surgical procedures. The use of box or virtual reality simulators in many surgical specialities is established; however, its use within trauma and orthopaedics (T&O) in the UK and the attitudes of trainee towards it are not known. The aim of this study is to explore the experiences and opinions of T&O trainees towards simulation training., Methods: An electronic survey consisting of 11 questions on the experiences of simulation training and attitudes towards it was sent to all T&O speciality trainees in London., Results: Fewer than 10% of the responders had used or had ready access to simulators to prepare for unfamiliar operations, with almost 90% preferring to read about them in a journal or watch them on an online video site. Over half had only seen simulators on courses or been aware of them. Over 75% of the responders believed that simulators should be available for trainees, but most did not feel that they should be used as part of formal assessments., Conclusions: Methods for preparing for new operations have expanded over the past 20 years, yet the use of simulator machines is not widespread. Many trainees believe current machines are not widely available nor realistic enough to be useful, with most preferring online videos and operative technique books for preparing for an unfamiliar operation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Medicinal plants have the potential treasure to treat medical conditions for a long time based on error and trial method. Agave americana has been known as century plant or American aloe. The leaves contain genins, saponins, steroidal flavonoids, isoflavones, and coumarins. It has long been used for anti-inflammatory effects., Objectives: This study was designed to evaluate the anti-inflammatory activity of the extract of A. americana ., Materials and Methods: A. americana leaves extract is collected and the extract is done by percolation method. Inflammation is induced in experimental animals' carrageenan-induced paw edema model and cotton pellet-induced granuloma model. The extract of A. americana and standard, aspirin and indomethacin are given orally for the anti-inflammatory effects. The anti-inflammatory effects were measured at regular intervals of time to see the percentage inhibition of paw edema and reduction of weight of granuloma with percentage protection to compare the effect of the extract with the control and standard., Results: The extract of A. americana showed improved in percentage inhibition of paw edema in graded doses of hydroalcoholic extract of A. americana (HEAA) as compared with control in carrageenan-induced paw edema model. The percentage inhibition of 400 mg/kg of HEAA at the 3 rd h is almost comparable with the standard, aspirin. On the other hand, graded doses (200 and 400 mg/kg) showed a highly significant reduction ( P < 0.001) in the weights of granuloma in comparison with the control in cotton pellet-induced granuloma model. The percentage inhibition of weight of granuloma by 400 mg/kg of HEAA is quite comparable to the standard, Indomethacin., Conclusion: Anti-inflammatory activity is seen with the graded dose of HEAA. The plant contains flavonoids and genins which have been shown to have anti-edematous effects in the acute phase of inflammation. Thus, the plant contributes to its anti-inflammatory activity. Thus, higher doses of A. americana leaves need to be used to have the better understanding of the mechanism of anti-inflammation., Summary: The hydroalcoholic extract from Agave americana (100, 200, and 400 mg/kg, HEAA) were studied in carrageenan-induced paw edema model and cotton pellet-induced granuloma model in Wistar rats. The plant contains flavonoids and genins which have been shown to have anti-edematous effects in the acute phase of inflammation. The results were good with the higher doses of 200 and 400 mg/kg of HEAA. Its in vivo anti-inflammatory activity is in good agreement with the traditional use of A. americana . Abbreviation Used: HEAA: Hydroalcoholic extract of Agave americana leaves; SEM: Standard error mean; ANOVA: Analysis of variance; n: Number; g: gram; w/w: weight by weight; h: hour; kg: kilogram; mg: milligram., Competing Interests: There are no conflicts of interest.

Aim: The study was designed for comparing the efficacy and cost effectiveness of Pregabalin and Duloxetine used in Diabetic Neuropathic Pain., Methods: The prospective interventional 6 month study was conducted in a diabetic clinic of a 500 bedded tertiary care hospital in South India. The subjects having diagnosed with diabetic neuropathy and not treated with Pregabalin and Duloxetine or any other drugs of its class were selected. The data were collected using NPS and Neuro QoL questionnaires. The cost of both drugs used in the study was calculated as the mean of the price of 3 leading common brands of those drugs. The comparative efficacy was calculated by comparing the mean difference produced by both drugs in NPS and QoL scores. The cost effectiveness were calculated by ICER ratio., Results: The results have shown a significant improvement in the mean difference of NPS and Neuro QoL scores of both Pregabalin (p=<0.001) and Duloxetine (p=<0.001) before and after the therapy, the Duloxetine dominates over Pregabalin in both. The mean cost of Pregabalin for 3 months therapy was found to be INR 668.7 and that for Duloxetine was INR 756. Duloxetine showed a better effect but more expensive. ICER ratio was calculated and found that a cost of INR 61.47 per extra QoL gained by Duloxetine., Conclusion: The study have revealed that, both drugs are found to be effective.On conducting cost effective analysis, a significant better improvement in QoL of patients was obtained by Duloxetine with comparatively mild increase in the price., (Copyright © 2016 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

Medical education in Texas is moving in the right direction. The Texas Medical Association has been a major partner in advancing medical education initiatives. This special symposium issue on medical education examines residency training costs, the Next Accreditation System, graduate medical education in rural Texas, Texas' physician workforce needs, the current state of education reform, and efforts to retain medical graduates in Texas.

Aim: To compare "consultation" and "hybrid" models of consultation-liaison (CL) services provided to patients visiting the medical emergency outpatient services., Materials and Methods: Over the period of 18 months, two different models of consultation psychiatry services (July 2012 to March 2013-consultation model, April 2013 to December 2013 hybrid model) were compared. In the consultation model, the psychiatry resident was available on call to the internists. Whereas, for the hybrid model psychiatry resident was stationed in the medical emergency and was available to assess the patients directly requiring psychiatric evaluation., Results: During the first 9 months, 22,000 patients were evaluated in various emergency medical outpatient services, of which 383 (1.74%) were referred to the on-call psychiatry CL team. However, when the hybrid model was followed, the number of patients evaluated by the psychiatry resident increased to 594 out of 24,737 patients (2.4%) who reported to the emergency during the next 9 months period. There was a substantial increase in the proportion of cases with medical illnesses for which psychiatric consultation was sought, and a change in psychiatric diagnostic profile was observed too. When compared to the consultation model, the hybrid model was associated with greater use of medications, investigations, referrals and psychological measures in the emergency setting itself., Conclusions: Following a hybrid model in the medical emergency leads to an increase in the number of total psychiatric consultations and more extensive management of patients.

Congenital hypothyroidism (CH) is one of the most common preventable causes of mental retardation in children. Early diagnosis and treatment prevent the devastating outcome of mental retardation. Clinical features of CH are subtle and are not evident early in the neonatal period. Therefore, universal newborn screening (NS) is effective in detecting CH and implementing early treatment. This article reviews the current literature regarding the epidemiology, etiology, classification, clinical features, diagnosis of primary CH, and the management of abnormal newborn screen as well as treatment and prognosis of primary CH and outlines the importance of universal newborn screening in preventing mental retardation.

Toxic epidermal necrolysis (TEN), also known as Lyell's syndrome, is a severe cutaneous drug reaction with a high mortality. Immune response is the possible cause in its pathogenesis. Levofloxacin is one of the most commonly used quinolones and has been reported to cause of TEN. On the other hand, furazolidone was proposed to augment the action of immediate hypersensitivity of levofloxacin by its cytotoxic effect and by the generation of free radicals. Here, we present a case of TEN where, levofloxacin and furazolidone were the probable cause of these adverse drug reactions.

Purpose: Consensus recommendations to help ensure safe insulin use in hospitalized patients are presented., Summary: Insulin products are frequently involved in medication errors in hospitals, and insulin is classified as a high-alert medication when used in inpatient settings. In an initiative to promote safer insulin use, the American Society of Health-System Pharmacists (ASHP) Research and Education Foundation convened a 21-member panel representing the fields of pharmacy, medicine, and nursing and consumer advocacy groups for a three-stage consensus-building initiative. The panel's consensus recommendations include the following: development of protocol-driven insulin order sets, elimination of the routine use of correction/sliding-scale insulin doses for management of hyperglycemia, restrictions on the types of insulin products stored in patient care areas, and policies to restrict the preparation of insulin bolus doses and i.v. infusions to the pharmacy department. In addition, the panelists recommended that hospitals better coordinate insulin use with meal intake and glucose testing, prospectively monitor the coordination of insulin delivery and rates of hypoglycemia and hyperglycemia, and provide standardized education and competency assessment for all hospital-based health care professionals responsible for insulin use., Conclusion: A 21-member expert panel convened by the ASHP Foundation identified 10 recommendations for enhancing insulin-use safety across the medication-use process in hospitals. Professional organizations, accrediting bodies, and consumer groups can play a critical role in the translation of these recommendations into practice. Rigorous research studies and program evaluations are needed to study the impact of implementation of these recommendations.

Adverse effects to antipsychotics are varied, frequently intolerable, often serious and sometimes fatal in clinical practice. Seizures are one of these adverse effects. Almost all first and second generation antipsychotics elicit dose-dependent lowering of seizure threshold, indicating increased seizure risk at higher drug dosages. The adverse event of zotepine induced seizure is published in few case reports. We report the occurrence of myoclonic seizure progressing to generalized tonic-clonic seizures with zotepine along with clear temporal association of dose dependent modulation evident in this case.

Background: Congenital complete heart block (CCHB) is an uncommon although important and potentially serious condition contributing to neonatal morbidity and mortality., Aims: To study the characteristics and outcomes of infants born with CCHB at a single tertiary centre., Methods: A retrospective review of all infants with CCHB over the last 20 years was carried out to determine the outcomes, and the indications and timing of pacemaker insertion., Results: Fifteen live born infants (10 male, 5 female) with CCHB were identified. Their mean (and SD) gestation and birth weight were 37 (3.3) weeks and 3100 (448) grams respectively. Maternal systemic lupus erythematosus (SLE) antibodies were present in eight (53%) pregnancies and two infants had congenitally corrected transposition of the great arteries (cCTGA). The median heart rate/minute at birth was 60 (range 40-80). Thirteen (87%) patients to date required a pacemaker. The median age of insertion of a pacemaker device was six months (range 2 days-16 years). All patients were paced epicardially - six initially with a single chamber and five with a dual chamber pacemaker. At the time of generator change, dual chamber pacemakers were used. The median life of an implanted pacemaker was six years (3-10 years). Except for a patient with cCTGA who has undergone a double switch procedure, all the patients had good systemic ventricular function. There was one death in the group unrelated to CCHB., Conclusions: CCHB is a uncommon but potentially serious condition in infancy. While a significant number of infants need a pacemaker, the overall outcome of infants with CCHB in our experience is good., (Copyright © 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Isoniazid and orlistat were reported to have inhibitory effect on mycobacterial ES-31 serine protease in vitro and bacterial cell growth in axenic culture., Aim: To study the cumulative effect and understand drug - drug interaction, if any, when isoniazid and orlistat used in combination., Material and Methods: Inhibition of mycobacterial ES-31 serine protease by different combinations of orlistat and isoniazid together and individually were studied using azocasein assay. Inhibition of secretion of excretory secretory ES-31 antigen in Sautan culture medium was studied under axenic condition and growth of M. tuberculosis H37Ra bacilli by CFU count on LJ-medium., Results: Orlistat and isoniazid both showed inhibitory activity of ES-31 serine protease in in vitro as well as in vivo. Individually, isoniazid showed 90% inhibition at 200 ng/ml while orlistat at 250 ng/ml showed 65% inhibition of mycobacterial ES-31 serine protease in vitro. A combination of orlistat (250 ng/ml) and isoniazid (200 ng/ml) showed 86% inhibition in vitro while 73% inhibition was observed by orlistat (25 ng/ml) and isoniazid (200 ng/ml) on bacterial growth in axenic culture., Conclusion: Significant inhibition by orlistat suggests that it could be tried in patients with intolerance to isoniazid or in those already developed isoniazid resistance. It may also be explored in the suspected TB patients as initial medication in place of antibiotics for clinical relief.

A case of conjoined twins after frozen embryo transfer at early blastocyst stage is described. The diagnosis was made early at 7 weeks by vaginal sonography and later confirmed by spatiotemporal image correlation with power Doppler. The value of spatiotemporal image correlation with Doppler in facilitating an early diagnosis of conjoined twinning is discussed., (Copyright © 2011 Wiley Periodicals, Inc.)

Background: There is scanty information on the outcome of adult congenital heart disease surgery from the developing world., Methods: This was a retrospective chart review of the surgical outcome of 153 adults with congenital heart disease over a 5-year period. Surgical atrial septal defect closure was considered "simple" while all other surgeries were considered "complex.", Results:   There were 102 patients in the "simple" group and 51 in the "complex" group. Only three (2%) patients had prior operations. The "complex" group had longer bypass time and cross clamp time. Intensive care unit stay, ventilation time, and inotrope administration were longer. Major complications were more common and there were two deaths in the "complex" group. Age more than 30 years, cyanosis, and New York Heart Association class more than II were predictors of longer stay in the intensive care unit. Surgical repair of Tetralogy of Fallot in adults tended to have a longer ventilation time and intensive care unit stay with a mortality of 4%. At follow up, all patients were in New York Heart Association class I or II. Improvement of the functional class with negligible adverse events was noted in both groups., Conclusions:   A retrospective evaluation of 153 adults with congenital heart disease who underwent open heart surgery at a single center in India showed strikingly fewer reoperations compared with large European studies. There was a similar prevalence of complex lesions. Surgical mortality was low, and long-term functional outcome was gratifying., (© 2011 Copyright the Authors. Congenital Heart Disease © 2011 Wiley Periodicals, Inc.)

This study aimed to assess critically the role of 64-slice multidetector-row computed tomographic (MDCT) angiography for evaluating congenital heart disease. The study enrolled 60 consecutive patients (median age, 4.7 years; median weight, 16.5 kg) with congenital heart disease who underwent 64-slice MDCT angiography during the period June 2006 through September 2007. The results were classified as diagnostic categories, and the impact of the procedure on strategizing management was critically analyzed. In each of the groups, the current technique offered a clear advantage over conventional imaging and provided specific clues for surgical/interventional management. A management algorithm was evolved based on questions frequently asked about pulmonary artery anatomy. The correlation with surgical anatomy in all cases that involved surgery was excellent. Early results suggest that 64-slice MDCT angiography is a major breakthrough in cardiovascular imaging with an important diagnostic and decision-aiding role. Diagnostic cardiac catheterization, especially for evaluating great vessel anomalies, could be largely replaced by the described technique for congenital heart disease.

Introduction and Aims: There are several studies in the literature suggesting that smoking increases the complication rate in various plastic surgery operations. We did a study on 402 patients to see the effect of smoking on breast reduction. The objective was to raise the controversial issue of whether breast reduction could be refused to smokers who fail to stop smoking in the peri-operative period., Materials and Methods: The records of patients who had undergone breast reductions between April 1999 and May 2004 at the Leicester Royal Infirmary, Leicester were reviewed retrospectively for age, body mass index, smoking habits and wound-related complications., Results: A total of 764 breast reductions were performed in 402 patients during this period. Twenty-eight per cent (112) of these patients were smokers. The mean age was 33.9 (range 19-68)+9.5 years in smokers and 34.4 (range 16-73)+10.6 years in non-smokers. About 90% of patients had bilateral breast reductions. Wound-related complications were seen in 35% of smokers as against 13% of non-smokers, P value<0.001. Overall, smokers had a 2.3 x higher chance of developing a complication. The probability of a smoker developing wound infection was 3.3 x more in comparison to a non-smoker. Smokers were also three times more likely to develop T-junction necrosis., Conclusion: Smoking increases the complication rate of breast reduction significantly. Hence, patients must be strongly encouraged to quit smoking before surgery and abstain until the wound has completely healed. Stoppage of smoking in the peri-operative period should be adopted as an essential eligibility criterion for breast reduction.

Unrecognized congenital hypothyroidism leads to mental retardation. Newborn screening and thyroid therapy started within 2 weeks of age can normalize cognitive development. The primary thyroid-stimulating hormone screening has become standard in many parts of the world. However, newborn thyroid screening is not yet universal in some countries. Initial dosage of 10 to 15 microg/kg levothyroxine is recommended. The goals of thyroid hormone therapy should be to maintain frequent evaluations of total thyroxine or free thyroxine in the upper half of the reference range during the first 3 years of life and to normalize the serum thyroid-stimulating hormone concentration to ensure optimal thyroid hormone dosage and compliance. Improvements in screening and therapy have led to improved developmental outcomes in adults with congenital hypothyroidism who are now in their 20s and 30s. Thyroid hormone regimens used today are more aggressive in targeting early correction of thyroid-stimulating hormone than were those used 20 or even 10 years ago. Thus, newborn infants with congenital hypothyroidism today may have an even better intellectual and neurologic prognosis. Efforts are ongoing to establish the optimal therapy that leads to maximum potential for normal development for infants with congenital hypothyroidism. Remaining controversy centers on infants whose abnormality in neonatal thyroid function is transient or mild and on optimal care of very low birth weight or preterm infants. Of note, thyroid-stimulating hormone is not elevated in central hypothyroidism. An algorithm is proposed for diagnosis and management. Physicians must not relinquish their clinical judgment and experience in the face of normal newborn thyroid test results. Hypothyroidism can be acquired after the newborn screening. When clinical symptoms and signs suggest hypothyroidism, regardless of newborn screening results, serum free thyroxine and thyroid-stimulating hormone determinations should be performed.

Aneurysms of the left main coronary artery are exceedingly rare clinical entities, encountered incidentally in approximately 0.1% of patients who undergo routine angiography. Thrombosis within the aneurysm can lead to distal embolization and myocardial infarction. These lesions can extend into adjacent coronary branches and can occur in the presence or absence of obstructive coronary disease. Depending on the severity of coexistent coronary stenoses, patients with left main coronary artery aneurysms can be effectively managed either operatively or medically. We report the cases of 2 patients who were treated medically for large left main coronary aneurysms and concomitant right coronary artery ectasia.