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In its first phase of exploitation, JT-60SA will be equipped with an inertially cooled divertor, which can sustain heat loads of 10 MW/m[sup 2] on the targets for a few seconds, which is much shorter than the intended discharge duration. Therefore, in order to maximize the duration of discharges, it is crucial to develop operational scenarios with a high radiated fraction in the plasma edge region without unacceptably compromising the scenario performance. In this study, the core and edge conditions of unseeded and neon-seeded deuterium H-mode scenarios in JT-60SA were investigated using METIS and SOLEDGE3X-EIRENE codes. The aim was to determine whether, and under which operational conditions, it would be possible to achieve heat loads at the targets significantly lower than 10 MW/m[sup 2] and potentially establish a divertordetached regime while keeping favorable plasma core conditions. In first analysis, an investigation of the edge parameter space of unseeded scenarios was carried out. Simulations at an intermediate edge power of 15 MW indicate that, without seeded impurities, the heat loads at the targets are higher than 10 MW/m[sup 2] in attached cases, and achieving detachment is challenging, requiring upstream electron densities at least above 4 χ 10[sup 19] m[sup -3]. This points toward the need for impurity injection during the first period of exploitation of the machine. Therefore, neon seeding simulations were carried out, performing a seeding rate scan and an injected power scan while keeping the upstream electron density at the separatrix at 3 χ 10[sup 19] m[sup -3]. They show that at 15 MW of power injected into the edge plasma, the inner target is easily detached and presents low heat loads when neon is injected. However, at the outer target, the heat fluxes are not lowered below 10 MW/m[sup 2], even when the power losses in the edge plasma are equal to 50% of the power crossing the separatrix. Therefore, the tokamak will probably need to be operated in a deep detached regime in its first phase of exploitation for discharges longer than a few seconds. In the framework of core-edge integrated modeling, using METIS, the power radiated in the core was computed for the most interesting cases. [ABSTRACT FROM AUTHOR]

Comminuted fractures of distal humerus are most commonly the result of high energy trauma. There is an extensive damage to soft tissues along with articular cartilage fragmentation and many a time associated with bone loss. Traditionally such bone voids are filled using a fibular strut graft. In this case report, reconstruction of lateral condyle of humerus, using a tricortical iliac crest graft has been described. A 37-year-old male sustained fracture of distal end of humerus with articular involvement of multifragmentary nature. There was severe comminution of the articular surface especially that of the lateral humerus condyle with bone void. To fill the bone void in the lateral column, tricortical iliac-crest graft was harvested from the ipsilateral iliac crest. Locking plates were applied medially and laterally, and fixation was done. After 6 months of follow-up, the patient showed good elbow range of motion (30 to 80 degrees) and the radiographs showed satisfactory union of the fracture with stable implants. There is also no significant graft donor site co-morbidity.For reconstruction of complex distal humerus fractures with bone void, tricortical iliac crest autologous bone graft can be considered as a feasible option apart from vascularised autologous bone graft and allograft.

Tuberculosis (TB) is a very common cause of morbidity and mortality as an infectious disease in endemic areas. Only 18 cases of scapular TB have been reported in the literature so far. In this case report, a patient was reported with tuberculosis of scapula without other typical manifestations of TB. A 54-year-old male presented with a painful progressive swelling of the left scapula for the past 6 months. The swelling was insidious in onset and progressed gradually and associated with a low grade intermittent fever. There were associated constitutional symptoms such as loss of appetite, loss of weight and non-productive cough. Erythrocyte sedimentation rate (ESR)levels were elevated and Mantoux test was positive. A plain radiograph of the chest was done which is normal. MRI findings were suggestive of Koch’s pathology. Incision and drainage of the swelling was undertaken which resulted in evacuation of copious amount of pus. Pus for TB culture revealed no growth of acid-fast bacilli (AFB) after 6 weeks. Final report of AFB fluorescent culture revealed growth of Mycobacterium tuberculosis complex. The patient was started on ATT regimen. On one year follow up, he is completely asymptomatic with ESR levels and total leukocyte count being within normal limits. Tuberculosis of the scapula is a rare presentation.Tubercular cold abscess should also be kept in mind when a person from a TB endemic area, presents with painful swelling of scapula with or without the associated constitutional symptoms of TB.

Introduction: Blount’s disease is defined as a growth disorder of medial aspect of proximal tibia physis with abrupt medial angulation of proximal tibia distal to epiphysis, leading to varus angulation of proximal tibia and medial rotation of tibia. Epidemiology is not well established and very rarely cases have been reported from Indian subcontinent. Presentation of case: A 3-years-old female child presented with deformity in both the legs and altered walking pattern for the past one year. On examination there was 15 degrees of varus deformity in both the knees. There was 25 degrees of internal tibial torsion bilaterally. The child was managed by surgical intervention. Oblique proximal tibial osteotomy was done. Fixation was done with a single cancellous screw on both sides and immobilisation was done in above knee plaster cast. Child recovered well with correction of deformity and could walk with normal gait pattern. Discussion: The cause of Blount’s disease is still not well established. Treatment depends upon age at presentation, severity of varus deformity as determined by Langenskiold staging, and progression of the disease. Early intervention is required to avoid progression of the disease and permanent deformity. Conclusion: Blount’s disease is a very rarely encountered condition in Indian subcontinent but has a characteristic presentation. It should be included in differential diagnosis in cases presenting with pathological bowing of legs. Radiological findings and normal blood biochemistry can guide us towards the diagnosis of Blount’s disease.

Importance: Severe gastrointestinal (GI) manifestations have been sporadically reported in children with COVID-19; however, their frequency and clinical outcome are unknown., Objective: To describe the clinical, radiological, and histopathologic characteristics of children with COVID-19 presenting with severe GI manifestations to identify factors associated with a severe outcome., Design, Setting, and Participants: A multicenter retrospective cohort study (February 25, 2020, to January 20, 2021) enrolled inpatient and outpatient children (aged <18 years) with acute SARS-CoV-2 infection, confirmed by positive real-time reverse-transcriptase-polymerase chain reaction on nasopharyngeal swab or fulfilling the US Centers for Disease Control and Prevention criteria for multisystem inflammatory syndrome in children (MIS-C). The study was conducted by pediatricians working in primary care or hospitals in Italy participating in the COVID-19 Registry of the Italian Society of Pediatric Infectious Diseases., Main Outcomes and Measures: The occurrence of severe GI manifestations, defined by a medical and/or radiological diagnosis of acute abdomen, appendicitis (complicated or not by perforation and/or peritonitis), intussusception, pancreatitis, abdominal fluid collection, and diffuse adenomesenteritis requiring surgical consultation, occurring during or within 4 to 6 weeks after infection with SARS-CoV-2 infection. Logistic regression was used to estimate odds ratios (ORs) with 95% CIs of factors potentially associated with severe outcomes., Results: Overall, 685 children (386 boys [56.4%]; median age, 7.3 [IQR, 1.6-12.4] years) were included. Of these children, 628 (91.7%) were diagnosed with acute SARS-CoV-2 infection and 57 (8.3%) with MIS-C. The presence of GI symptoms was associated with a higher chance of hospitalization (OR, 2.64; 95% CI, 1.89-3.69) and intensive care unit admission (OR, 3.90; 95% CI, 1.98-7.68). Overall, 65 children (9.5%) showed severe GI involvement, including disseminated adenomesenteritis (39.6%), appendicitis (33.5%), abdominal fluid collection (21.3%), pancreatitis (6.9%), or intussusception (4.6%). Twenty-seven of these 65 children (41.5%) underwent surgery. Severe GI manifestations were associated with the child's age (5-10 years: OR, 8.33; 95% CI, 2.62-26.5; >10 years: OR, 6.37; 95% CI, 2.12-19.1, compared with preschool-age), abdominal pain (adjusted OR [aOR], 34.5; 95% CI, 10.1-118), lymphopenia (aOR, 8.93; 95% CI, 3.03-26.3), or MIS-C (aOR, 6.28; 95% CI, 1.92-20.5). Diarrhea was associated with a higher chance of adenomesenteritis (aOR, 3.13; 95% CI, 1.08-9.12) or abdominal fluid collection (aOR, 3.22; 95% CI, 1.03-10.0)., Conclusions and Relevance: In this multicenter cohort study of Italian children with SARS-CoV-2 infection or MIS-C, 9.5% of the children had severe GI involvement, frequently associated with MIS-C. These findings suggest that prompt identification may improve the management of serious complications.

Background: COVID-19, a disease caused by the new coronavirus SARS-CoV-2, spread worldwide, and Bergamo was one of the most affected areas in Europe. Following the first outbreak, more than half of the population of the Bergamo province had been infected. We aimed to describe the patients admitted to our unit shortly after the first outbreak. Methods: we retrospectively reviewed the notes of all pediatric patients diagnosed with COVID-19. We enrolled patients with positive swabs or serology and classified them based on the pattern and the timing of presentation after the first outbreak. This setting was considered a reliable reflection of the consequences of unmitigated SARS-CoV-2 circulation. Results: We diagnosed 35 patients over a 3-month period and we identified six patterns presenting in two temporal phases: Early phase, Group 1 (median of 20 days from epidemic start, IQR: 15-27): neonatal sepsis ( n .7), pneumonia ( n .5), flu-like symptoms ( n .2). Late phase, Group 2 (59:51-66 days, p < 0.001): MIS-C ( n .18), neurological manifestations ( n .3). Group 1 differed from Group 2 for younger age (1 vs. 8 years, p = 0.02), lower C-reactive protein (0.9 vs. 16.6 mg/dl, p = 0.008), procalcitonin (0.16 vs. 7.9 ng/ml, p = 0.008) and neutrophil count (3,765 vs. 6,780/μl, p = 0.006), higher rate of positive swabs (14/14 vs. 9/21, p < 0.001), higher lymphocyte count (3,000 vs. 930/μl, p = 0.006) and platelet count (323,000 vs. 210,000/μl, p = 0.009). Conclusions: Following an outbreak of unmitigated SARS-CoV-2 diffusion, infected children may present with clinical patterns suggesting two temporal clusters, the first characterized by markers of direct viral injury, the second suggesting an immune-mediated disease., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Mazza, Di Giorgio, Martelli, Pelliccia, Pinotti, Quadri, Verdoni, Decio, Ruggeri and D'Antiga.)

Introduction: Iliotibial band (ITB) friction syndrome is a common overuse injury typically seen in active athlete population. A nodular lesion on the inner side of the ITB as an etiology or an accompanying lesion with friction syndrome has rarely been reported. Among such nodular lesions around knee, fibroma of tendon sheath (FTS) is a rare occurrence. All the more intra-articular occurrence is extremely rare., Case Report: A 16-year-old female presented with recurrent pain and movable nodule at the lateral joint area, diagnosed as ITB friction syndrome. The nodule was confirmed as rare intra-articular FTS on the basis of histopathology findings., Conclusion: When nodular lesions around knee are detected on magnetic resonance imaging, a FTS could be included in the differential diagnosis. Etiology and pathogenesis of ITB friction syndrome should be revised in view of such rare presentations., Competing Interests: Conflict of Interest: Nil