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Key Clinical Message Hepatocellular carcinoma (HCC) is one of the most common types of cancer. More focus is being placed on clinical presentations of distant metastasis from HCC. Head masses should be investigated even when no concerning symptoms are found in patients with prior history of alcohol abuse and liver comorbidities.

Introduction: The Fontan operation is a surgical technique used to treat cyanotic heart diseases with single ventricle physiology. Although it has undergone several modifications since its inception in 1971, it is still associated with significant morbidity and mortality. Aim: To examine the outcomes of the Fontan operation and identify various risk factors associated with it. Materials and Methods: This retrospective observational study was conducted at the Postgraduate Institute of Medical Education and Research (PGIMER) in Chandigarh, India from January 2014 to December 2017. All patients who underwent the Fontan operation at PGIMER were included in the study. The study analysed outcomes such as survival, arrhythmias, neurological complications, heart failure, cirrhosis, and Protein Losing Enteropathy (PLE) following the Fontan operation. Various risk factors that could potentially influence the outcome of the Fontan operation were assessed, including preoperative, intraoperative, and postoperative factors. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software, version 25.0. The Chi-square test was utilised to determine predictors of survival and other longterm outcomes, with a p-value of

Over the years, research regarding the Zika virus has been steadily increasing. Early immunization for ZIKV is a priority for preventing complications such as microencephaly and Guillain–Barré syndrome (GBS). Unlike traditional vaccination approaches, oral dissolving films (ODFs) or mucoadhesive film technology is an emerging, exciting concept that can be used in the field of pharmaceuticals for vaccine design and formulation development. This attractive and novel method can help patients who suffer from dysphagia as a complication of a disease or syndrome. In this study, we investigated a microparticulate Zika vaccine administered via the buccal route with the help of thin films or oral dissolving films (ODFs) with a prime dose and two booster doses two weeks apart. In vitro, the ODFs displayed excellent physiochemical properties, indicating that the films were good carriers for vaccine microparticles and biocompatible with the buccal mucosa. In vivo results revealed robust humoral (IgG, subtypes IgG1 and IgG2a) and T-cell responses (CD4+/CD8+) for ZIKV-specific immunity. Both the Zika MP vaccine and the adjuvanted Zika MP vaccine affected memory (CD45R/CD27) and intracellular cytokine (TNF-α and IL-6) expression. In this study, ZIKV vaccination via the buccal route with the aid of ODFs demonstrated great promise for the development of pain-free vaccines for infectious diseases.

Humans continue to be at risk from the Zika virus. Although there have been significant research advancements regarding Zika, the absence of a vaccine or approved treatment poses further challenges for healthcare providers. In this study, we developed a microparticulate Zika vaccine using an inactivated whole Zika virus as the antigen that can be administered pain-free via intranasal (IN) immunization. These microparticles (MP) were formulated using a double emulsion method developed by our lab. We explored a prime dose and two-booster-dose vaccination strategy using MPL-A® and Alhydrogel® as adjuvants to further stimulate the immune response. MPL-A® induces a Th1-mediated immune response and Alhydrogel® (alum) induces a Th2-mediated immune response. There was a high recovery yield of MPs, less than 5 µm in size, and particle charge of −19.42 ± 0.66 mV. IN immunization of Zika MP vaccine and the adjuvanted Zika MP vaccine showed a robust humoral response as indicated by several antibodies (IgA, IgM, and IgG) and several IgG subtypes (IgG1, IgG2a, and IgG3). Vaccine MP elicited a balance Th1- and Th2-mediated immune response. Immune organs, such as the spleen and lymph nodes, exhibited a significant increase in CD4+ helper and CD8+ cytotoxic T-cell cellular response in both vaccine groups. Zika MP vaccine and adjuvanted Zika MP vaccine displayed a robust memory response (CD27 and CD45R) in the spleen and lymph nodes. Adjuvanted vaccine-induced higher Zika-specific intracellular cytokines than the unadjuvanted vaccine. Our results suggest that more than one dose or multiple doses may be necessary to achieve necessary immunological responses. Compared to unvaccinated mice, the Zika vaccine MP and adjuvanted MP vaccine when administered via intranasal route demonstrated robust humoral, cellular, and memory responses. In this pre-clinical study, we established a pain-free microparticulate Zika vaccine that produced a significant immune response when administered intranasally.

Background: Radiological markers that are useful in the diagnosis of normal pressure hydrocephalus include the Bicaudate index (BCI) and the Evans index (EI), which are practical indicators of ventricular volume. Worldwide, variation exists in normative studies for both these indices. The majority of research for EI and BCI is based on data from the Western population. The study has been performed on the South Karnataka population. Aims and Objectives: This study’s goal is to derive age and gender specific cutoff values on normative data of Evans and BCI. Materials and Methods: This was a prospective and observational study.Patients referred to “RL Jalappa Hospital” for computed tomography (CT) scan of the brain who meet the inclusion criteria will be included in this study. CT brain of all the patients will be performed in Siemens Somatom emotion 16 slice CT scanner. Ninety-seven were selected for this study, and EI and BCI were calculated for them. Results: The mean value of EI and BCI in our study was 0.26±0.02 and 0.1167±0.02, respectively. The difference in EI and BCI between males and females shown significant statistical difference between males and females but the values increased as increase in age. Conclusion: Our study for South Indian population concludes that EI and BCI have a significant statistical difference between males and females. Both EI and BCI values increase with age. Hence cutoff values of EI and BCI index according to age and gender are important for evaluation of hydrocephalus.

Objective B-lymphocyte progenitors, namely the hematogones (HGs), may pose problems in morphological assessment of bone marrow, not only during the diagnostic workup but also while evaluating bone marrow for remission status following chemotherapy. Here, we describe a series of 12 cases of acute lymphoblastic leukemia (ALL) that included both B-ALL and T-ALL cases, which were evaluated for remission status and revealed blast-like mononuclear cells in bone marrow in the range of 6 to 26%, which on immunophenotypic analysis turned out to be HGs. Materials and Methods This is a case series of 12 ALL cases who were undergoing treatment at the Army Hospital (Referral and Research), New Delhi. All these cases were under workup for post-induction status (day 28) and to check for suspected ALL relapse. Bone marrow aspirate (BMA), biopsy, and immunophenotyping were performed. Multicolored flow cytometry was performed using CD10, CD20, CD22, CD34, CD19, and CD38 antibodies panel. Results BMA assessment of 12 cases revealed a maximum of 26% blastoid cells and a minimum of up to 6%, raising the suspicion of hematological relapse. However, on clinical assessment, these patients were well preserved, with preserved peripheral counts. Hence, marrow aspirates were subjected to flow cytometry using the CD markers panel, as discussed above, which revealed HGs. These cases were followed by minimal residual disease (MRD) analysis that revealed MRD-negative status, further confirming our findings. Conclusion This case series highlights the importance of morphology and bone marrow immunophenotyping in unveiling the diagnostic dilemma in post-induction ALL patients.

The novel coronavirus disease (COVID-19) was caused by a new strain of the virus SARS-CoV-2 in December 2019 emerged as deadly pandemic that affected millions of people worldwide. Factors such as lack of effective drugs, vaccine resistance, gene mutations, and cost of repurposed drugs demand new potential inhibitors. The main protease (Mpro) of SARS-CoV-2 has a key role in viral replication and transcription and is considered as drug target for new lead identification. In this present work, structure-based virtual screening, docking, MM/GBSA, AutoDock, ADME, and MD simulations-based optimization was proposed for the identification of new potential inhibitors against Mpro of SARS-CoV-2. The ligand molecules M1, M3, and M6 were identified as potential leads from lead optimization. Induced fit docking was performed for the identification of the best poses of lead molecules. The best docked poses of potential leads M1 and M3 were subject to 100 ns MD simulations for the evaluation of stability and interaction analysis into Mpro active site. The structures of the top two leads M1 and M3 were optimized based on MD simulation conformational changes and isoster scanning, designed as new leads M7 and M8. The MD simulation trajectories RMSD, RMSF, protein-ligand, ligand-protein interaction plots, and ligand torsion profiles were analyzed for stability interpretation. The docked complexes of M7 and M8 of Mpro exhibited equilibrated and converged plots in 100 ns simulation. The lead molecules M1, M3, M7, and M8 were identified as potential SARS-CoV-2 inhibitors for COVID-19 disease. A comparative docking study was carried out using FDA-approved drugs to support the potential binding affinities of newly identified lead inhibitors.

Background: Myectomy is the surgical procedure for the treatment of hypertrophic cardiomyopathy (HCM) with refractory symptoms There is limited data available regarding the role of myectomy in HCM among the Indian population. This study is intended to assess the outcomes of myectomy in HCM. Methods: Change in the gradient across the left ventricular outflow tract and severity of mitral regurgitation after myectomy were studied using echocardiography. Functional status, exercise tolerance, and cardiac rhythm of the patients were studied before and after myectomy. Results: The study consists of eleven patients with HCM. Four patients were in NYHA grade II, seven were in NYHA grade III before surgery. After surgery nine were in NYHA grade I and two were in NYHA grade II. Exercise tolerance of the study group was in the range of 1 min before surgery and it improved to 6.27 min after surgery. LVOT gradient before surgery was 108.81 and 112.45 mm of Hg on TTE and TEE respectively and it was 17.9 and 15.63 mm of Hg on TEE and TTE respectively after myectomy. On TTE eight patients had severe MR and three had moderate MR before surgery, while nine of them had severe MR and two had moderate MR on TEE. In the immediate post-operative period nine had mild MR, one had moderate MR, whereas the remaining one patient underwent MVR. TTE at six months revealed mild MR in seven, moderate MR in two patients and one had no MR. Conclusions: Surgical septal myectomy is an effective treatment modality for obstructive HCM.

Background: Squamous cell carcinoma is the most prevalent kind of tumor of the buccal mucosa. For the purpose of planning surgery and radiotherapy for tumors of the tongue, floor of the mouth, and oropharyx, imaging to locate the size and extent of the original tumor is essential. Therefore, it is beneficial to determine the radiation field, to ensure adequate tumor margin excision, and overall to improve the patient’s prognosis. Aims and Objectives: The aim of the study was to evaluate the role of computed tomography (CT) scan in diagnosis of buccal mucosal malignancies and its characteristics. Materials and Methods: Total 50 patients suspecting buccal mucosa cancer were referred to Radiology Department. They were subjected for CT scan examination on 16 slice CT scanner. CT scan evaluation was made for size and extent of primary mass lesion. The staging of disease was performed with TNM classification. Results: In our study, out of 50 patients, the fourth decade (30%) and fifth decade (26%) saw the highest incidence of buccal mucosa cancer. The majority of the patients were suffering from severe disease; 44% had T4 stage and 58% had Stage IV. Conclusion: CT plays a very important role in staging of buccal mucosa malignancy and effectively detects bone erosion (98% sensitive) and invasion to infratemporal fossa. However, during the early stages of cancer, a CT scan might not be very helpful.

In recent scenarios, self-compacting concrete (SCC) has played a vital role in the construction industry. In the fresh state, SCC has flow ability, passing ability, and filling ability. SCC also had better strength and durability properties. The addition of fiber content in SCC could improve the tensile properties. The present research aims to investigate the strength aspects of SCC using a combination of steel fibers with mineral admixture namely Ground Granulated Blast Furnace Slag (GGBS) in constant 30%. The fresh properties of SCC were highly influenced by GGBS since it is used as a powder content/ fines. However, the addition of steel fibers (STF) from 0% to 2% with an increment of 0.5% has decreased the flowability property in SCC. From the obtained results, the addition of 2% STF along with 30% GGBS has improved the strength when compared to the control mix of the same grade and also resisted the crack propagations.

Background: Plantar fascitis causes heel pain and the thickened fascia has specific morphological features that can be utilized for early diagnosis through sonoelastographic evaluation. Aims and Objectives: This case–control study was conducted to find out the role of sonoelastography in the diagnosis of plantar fasciitis (PF). Materials and Methods: A case–control study was conducted in the department of radiodiagnosis in a teaching medical college. Thirty clinically diagnosed PF patients and thirty controls were recruited based on selection criteria. Shear wave elastography (SWE) was done for all participants and the thickness of plantar fascia and strain ratio was compared between the groups. Plantar fascia thickness (mm) and elasticity (stain ratio) were considered as the primary outcome variable. coGuide software was used for data analysis. Results: The mean age of the cases was 46.73±16.92 years and controls was 47.5±16.1 years. There was no statistical difference observed between cases and controls in age, sex, and body mass index. There was a statistically significant difference in thickness of the plantar fascia (P

Medication nonadherence following myocardial infarction (MI) is prevalent and increases the risk of recurrent cardiovascular events. Socioeconomic factors including medication cost, financial insecurity, and poor health literacy are associated with nonadherence. We present a patient with a history of recurrent MI who was nonadherent due to socioeconomic challenges. Our patient subsequently developed ST-elevation MI secondary to in-stent thrombosis. This case illustrates the importance of pre-discharge screening for barriers to adherence.

This article presents a database which contains a comprehensive and systematically varied set of network instances. These can be applied as benchmarks for multiple road repair and restoration problems in the context of natural disasters. The characteristics of the instances vary in terms of network size, intensity and type of disaster affecting the road network, the epicenter's location, and the number of sub-networks in which the initial network is divided after the disaster occurs. The instances were developed primarily for the Multi-vehicle Prize Collecting Arc Routing for Connectivity Problem (KPC-ARCP). These are however easily adaptable to other well-known connectivity, vehicle routing, and facility location problems in the Operations Research literature. The instances are available on a public repository, as is the Python code to generate the instances.

Perhaps in no other area of neurosurgery, has a greater research been done as in traumatic brain injury (TBI). Despite this, TBI remains one of the biggest killers around the world and especially in India. Decompressive craniotomy still remains one of the mainstay paradigms in the management of TBI. The following article explores several new modalities of treatment, and these include the role of beta-blockers for TBI, updates on decompressive craniotomy, the results of DECRA and RESCUEicp trials, diagnostic and prognostic biomarkers in TBI, vascular dysfunction, neuroimaging, and role of neuroinflammation in TBI.

To make machines more human-like, computer vision is essential. Computer vision is a field that focuses on mimicking the capabilities of the human visual framework to capture high-level understanding from enhanced images or recordings. Such a computer vision application gives the machine the ability to recognize a person and detect their emotions in order to process them appropriately. Facial verification can be a process of identifying or validating an object through an image, video, or any audio-visual component of their face. It could be a biometric discriminant proof strategy that works directly and confronts measures of discriminating individuals through their facial design and biometric information. The innovation collects a unique set of biometric information from each individual regarding their face and facial expressions to identify an individual. Facial sensory recognition can be an innovation used to analyse estimates from a variety of sources, such as images and recordings. It makes a difference as machines get better the way humans do and treat them according to their emotions. We are using a deep learning computation called Convolutional Neural Networks (CNN) to prepare for this demonstration that determines the sentiment of certain input images. We need to pre-process the images to prepare and test the model. For pre-processing, we do image enhancement combining resizing, equalizing and converting the image to grayscale for the machine to achieve. This demonstration can have multiple applications in both surveillance and feedback systems.

Introduction: Neuroparalytic snake bite is a serious life-threatening hazard all over the world, especially in tropical countries of South-East Asia. But it is one of the most neglected tropical diseases. Patients can present with envenomation signs without a history of snakebite or an identifiable bite mark. Apart from neuroparalysis, symptoms of autonomic dysfunction can also be seen with krait envenomation. Case Report: 11-year-old girl presented with early morning sudden onset altered sensorium. On examination found to have absent spontaneous respirations, severe hypertension, dilated pupils, and absent brainstem reflexes, so labeled as probable brain death. Later with control of hypertension, she was able to respond by blinking but had severe neuroparalysis. There was no evidence of snakebite but with a strong suspicion of krait envenomation, anti-snake venom was given empirically and continued ventilatory support, following which child had a complete recovery. Discussion: As the majority of krait bites occur during sleep and due to its painless nature, they often go unnoticed. Also, krait bite leaves very fine puncture marks and the local reaction is markedly absent, so fang marks couldn’t be easily identified. Autonomic dysfunction following krait envenomation can present as abdominal pain, vomiting, sweating, mydriasis, fluctuation of heart rate and blood pressure, and paralytic ileus. In severe krait envenomation, complete paralysis of all voluntary muscles leads to quadriplegia and anathria which resembles locked-in syndrome. Locked-in syndrome when associated with internal ophthalmoplegia can mimic brain death. Conclusion: Snakebite should be considered in the differential diagnosis of unexplained neuroparalysis and hypertension. Envenomation should not be excluded by the absence of a history of snakebite or identifiable bite mark.

The aberrant right subclavian artery (ARSA, arteria lusoria) is the most common intrathoracic vascular anomaly, affecting up to 2% of the population. However, aneurysms of congenital anomalies are extremely unusual and often present with dysphagia, dysphonia, or dyspnea due to compression of the surrounding structures. We report a case of an asymptomatic 57-year-old male with chronic kidney disease who was incidentally found to have a large aneurysm of the ARSA on preoperative computed tomography for laparoscopic nephrectomy. Surgery is unequivocally warranted as these aneurysms are associated with a high risk of complications, including thrombosis, embolism, and rupture. We debranched the ARSA, followed by anastomosis to the right carotid artery through a right neck incision. Subsequently, aneurysmal resection was performed through left thoracotomy. The patient had an uneventful postoperative recovery and was asymptomatic during the follow-up.

Introduction: The current Coronavirus Disease-19 (COVID-19) pandemic is considered as one of the most serious public health crises which caused more than 1.62 million deaths from October 2020 to November 2020. Acute respiratory failure is leading cause of death followed by sepsis, cardiac failure and haemorrhage. Since the pathological findings are diverse in COVID-19 and majority of studies in literature were by open autopsy; the present study was done using percutaneous core needle biopsy. Postmortem lung biopsies are rather easy and quick to perform and decrease the infective risk caused by full autopsies. This could be an essential tool for diagnosis, surveillance and research. Aim: To study the pathological features of lung in COVID-19 deceased patients by postmortem. Materials and Methods: This cross-sectional study was conducted in the Department of Pulmonary Medicine, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, Andhra Pradesh, India from October 2020 to November 2020. In present study, postmortem percutaneous core needle biopsies from lung were performed within two hours of death from eight deceased patients who died of COVID-19. Clinical history, inflammatory markers and treatment details were collected from case sheets, biopsy was done, specimen was collected and sent for pathological examination. Data was presented in the descriptive form for each variable. Results: Out of eight cases, five were men and three were women with a mean age of 54.12 years. Majority of patients presented with complaints of shortness of breath and fever. Hypertension, type 2 diabetes mellitus, obesity, hypothyroidism, history of pulmonary tuberculosis were the co-morbidities noticed. Four biopsies presented acute lung injury with hyaline membrane changes, Diffuse Alveolar Damage (DAD) with hyaline membrane was seen in two cases, squamous metaplasia was seen in two cases and acute lung injury with organising pneumonia was seen in two cases. Conclusion: Postmortem lung biopsies are safe, easy to perform and provide insights of possible undergoing pathology of the disease with regard to clinical presentation.

Background Sentinel lymph node (SLN) is the first node to receive the drainage directly from a tumor. SLN biopsy can be done in lieu of a formal lymphadenectomy in selected clinically node-negative cancers and minimizes morbidity compared with the latter. Methods This prospective study was done in patients with operable clinically node-negative breast cancer, penile cancer, and malignant melanoma of extremities in a cancer center of North-east India from January 2019 to December 2019. All the patients underwent formal lymph nodal dissection after the SLN biopsy. Besides intraoperative frozen section study of the sentinel node(s), all the specimens, including the sentinel node(s), were subjected to paraffin section histopathology. Results SLN was identified successfully in 96% of patients. Mean number of sentinel node(s) dissected was 2.3. Study of SLN biopsy with methylene blue dye for staging was done with 100% sensitivity and 95.3% specificity. The SLN procedure was able to negatively predict the drainage nodal basin in 100% with an overall accuracy of staging of 96.5%. The true-positive rate noted was 88.8%, and the false-positive rate was 4.6%. Conclusions SLN using a single-dye technique reliably identifies a sentinel node. This procedure can be safely adopted in patients with node-negative cancers as mentioned above to pathologically study the drainage basin.

Abstract Background Incidence of foreign body aspiration has been noticed predominantly in age group ranging from 12 months-3 years. Foreign body in the trachea is a medical emergency as presentation is in respiratory distress. Obstruction of only one main or distal bronchus, leads to severe cough, choking sensation and breathlessness. Without early intervention, it can lead to collapse, consolidation and pneumonia of the affected lung. Methods We retrospectively analyzed 37 pediatric case records who presented from January 2014–December 2018 with foreign body aspiration. Our primary aim was to assess the parameters responsible for early and late diagnosis of foreign body aspiration. We concluded with a diagnostic algorithm for management of foreign body aspiration on the basis of this outcome. Results Around 32.5% came with a history of aspiration, 43% were referred from the primary centers with a suspicion for the same and the rest came to our tertiary care hospital directly. Those who presented within a week came with complaints of wet cough, wheeze and tachypnea. Furthermore, those who came in after a week had a dry cough and fever as their main complaint. Majority of ingested foreign bodies was a vegetative type (80%) as compared to the non –vegetative. Conclusion Unlike adults, foreign body aspiration in children is most commonly diagnosed on history, suspicion and clinical findings. Chest x ray has been the primary investigation of choice but in the majority of the cases it was normal with subtle changes. Early diagnosis is the key to avoid complication.

Background: Laminoplasty is a method of posterior cervical decompression which indirectly decompresses the spinal column. Unfortunately, many patients undergoing laminoplasty develops postoperative loss of cervical lordosis (LCL) or kyphotic alignment of cervical spine even though they have sufficient preoperative lordosis which results in poor surgical outcome. Objective: We would like to highlight the relationship between various radiological parameters of cervical alignment and postoperative LCL in patients undergoing laminoplasty. Methods: We performed extensive literature search using PubMed, Google Scholar, and Web of Science for relevant articles that report factors affecting cervical alignment following laminoplasty. Results: On reviewing the literature, patients with high T1 slope have more lordotic alignment of cervical spine preoperatively. They also have more chances of LCL following laminoplasty. C2–C7 sagittal vertical axis (SVA) has no role in predicting LCL following laminoplasty though patients with low T1 slope (≤20°) and high C2–C7 SVA (>22 mm) had correction of kyphotic deformity following laminoplasty. C2–C7 lordosis, Neck Tilt, cervical range of motion, and thoracic kyphosis has no predictive value for LCL. Lower value of T1 slope (T1S-CL) and CL/T1S has more incidence of developing LCL following laminoplasty. The role of C2–C3 disc angle has not yet been evaluated in patients undergoing laminoplasty. Dynamic extension reserve determines the contraction reserve of SPMLC and lower dynamic extension reserve is associated with higher chances of LCL following laminoplasty. Conclusions: Cervical lordotic alignment is important in maintaining cervical sagittal balance which ultimately is responsible for global spinal sagittal balance and horizontal gaze. Among various radiological parameters, T1 Slope has been reported to be the most important factor affecting cervical alignment following laminoplasty.

The Fontan procedure was created to address the mixing of pulmonary and systemic venous return in patients with a single functional ventricle. The patient in this case with a Fontan repair experienced multiple pulmonary emboli 10 days post-partum. We outline management and recommendations when treating these patients. (Level of Difficulty: Beginner.)

Background: COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-II) has become a global pandemic disrupting public health services. Telemedicine has emerged as an important tool to deliver care during these situations. Patients receiving Vitamin K antagonists (VKA) require structured monitoring which has posed a challenge during this pandemic. We aimed to evaluate the impact of Virtual anticoagulation clinic (VAC), a Telehealth model on the quality of anticoagulation, adverse events, and patient satisfaction vis-a-vis standard Anticoagulation clinic (ACC) care.Materials and methods: A bidirectional cohort study was conducted in the Department of Cardiology, JSS Hospital, Mysore. Two hundred and twenty-eight patients in the VAC and 274 patients in the ACC fulfilling inclusion criteria were the subjects of the study. Telehealth tools like WhatsApp and telephone were used. Time in therapeutic range (TTR), Percentage of International normalized ratio in range (PINRR), and adverse events were analyzed and compared between the VAC group and the ACC group, between pre-COVID and COVID ACC groups, and between the VAC group and the same pre-COVID cohort. Patient satisfaction was assessed by a questionnaire at the end of 8 months. Descriptive statistics were used for the patient characteristics and inferential statistics for the comparisons between pre-VAC and VAC care.Results: The mean TTR was 75.4 ± 8.9% and 71.2 ± 13.4% in the VAC group and ACC group, respectively (p < 0.001). The mean PINRR was 66.7 ± 9.4% and 62.4 ± 10.9% in the VAC group and ACC group respectively, (p < 0.001). There was no significant difference in TTR between the VAC group and the same pre-COVID cohort. The TTR differential between the pre-COVID and COVID ACC groups was significant. In either group, no major adverse events were seen. The most common tools used for data exchange were WhatsApp (83%) and SMS (17%). Seventy-four percent of patients were extremely satisfied with the overall VAC care.Conclusions: Virtual anticoagulation clinic, a telehealth model can be used as an alternative option to deliver uninterrupted anticoagulation care during pandemic times.

In certain occupations, injuries and microtrauma are commonly encountered by the soft tissues of the hand in the adult population, which may, however, less frequently lead to arterial occlusion. One such example is that of the Hypothenar Hammer Syndrome (HHS). It is a rare traumatic disease of the hand, caused by blunt traumas to the heel of the hand that may damage the ulnar artery at the level of hypothenar eminence. This results in occlusion or aneurysm of the vessel. It is of clinical importance due to the risk of loss of limb function following digital ischemia. The ulnar nerve barely gets compressed in the Guyon’s canal, which may in turn cause Guyon’s canal syndrome. This is a case of a 43-year-old male patient who presented with painful swelling of the right hand, which was diagnosed as a bizarre presentation of a bilobed and partially thrombosed pseudoaneurysm of the ulnar artery producing Guyon’s canal syndrome that had to be surgically excised. The objective of this case is to highlight the clinical presentation of HHS for early diagnosis and treatment.

Background: Evidence on recent trends regarding the impact and cost-benefits of ultrasound in resource-constrained settings is limited. This study presents a systematic review to determine recent trends in the utility and applicability of ultrasound use in low and middle income countries (LMIC). The review includes characterizing and evaluating trends in (1) the geographic and specialty specific use of ultrasound in LMICs, (2) the innovative applications and the accompanying research findings, and (3) the development of associated educational and training programs. Methods: The electronic databases Medline OVID, EMBASE, and Cochrane were searched from 2010 to 2018 for studies available in English, French, and Spanish. Commentaries, opinion articles, reviews and book chapters were excluded. Two categories were created, one for reported applications of ultrasound use in LMICs and another for novel ultrasound studies. Results: A total of 6,276 articles were identified and screened, 4,563 studies were included for final review. 287 studies contained original or novel applications of ultrasound use in LMICs. Nearly 70% of studies involved ultrasound usage originating from Southeast Asia and sub-Saharan Africa, the latter being the region with the highest number of innovative ultrasound use. Educational studies, global collaborations, and funded studies were a substantial subset of overall ultrasound research. Our findings are limited by the lack of higher quality evidence and limited number of randomized clinical trials reported. Conclusion/Global Health Implications: Our systematic literature review of ultrasound use in LMICs demonstrates the growing utilization of this relatively low-cost, portable imaging technology in low resource settings. Key words: • Ultrasound • Ultrasonography • Echocardiogram • LMIC • Low resource • Global health • Systematic review Copyright © 2020 Stewart et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Neonatal Varicella is an uncommon disease in the Indian population, due to the presence of antibodies in the mother formed on the exposure to illness in their teenage in majority of population. The acquired varicella in newborn period, born to a non-immune mother shows a disseminated disease pattern with poor prognosis and high risk of mortality due to pneumonia, hepatitis, coagulopathy and secondary severe sepsis. The definite diagnosis is made by virus isolation or amplification of viral DNA from the skin lesions by PCR, but the clinical diagnosis from the pattern of rash hints the diagnosis well and appropriate. The drug of choice is intravenous acyclovir and Varicella Zoster Immune Globulin (VZIG), although the use of VZIG still remains debatable in symptomatic individuals. Here, we present a case of a 15-day-old newborn with confluent maculo-papular rash preceded by rash in the mother at 10th day post-delivery. The newborn was managed in NICU with standard protocols, but the prognosis became poor due to complications that were pneumonia, hepatitis and secondary sepsis.

Thalassemia is an inherited defect in the production of globulin chains transmitted by autosomal recessive inheritance. Anaesthetic management of these patients is challenging, being associated with hypersplenism, unanticipated difficult airway and vertebral malformations, perioperative high blood pressure, systemic features of iron overload, cardiac and hepatic failure and anaemia. In this case, we highlight the anaesthetic concerns in a child of beta thalassemia intermedia with high levels of Hemoglobin F posted for splenectomy along with cholecystectomy. To avoid need of postoperative mechanical ventilation due to low oxygen carrying capacity of blood and anaerobic metabolism during the period of surgical stress, epidural catheter inserted despite possibility of epidural hematoma or bleed because of thrombocytopenia. Patient had an enhanced recovery in term of decrease oxygen demand, decrease postoperative nausea and vomiting, early ambulation and patient satisfaction. Intraoperative epidural also decreases need of neuromuscular blocking agent and intravenous analgesia. This lead to faster awakening from anaesthesia even in the presence of decrease oxygen carrying capacity due to anaemia and acidosis (anaerobic metabolism). Use of regional anesthesia should be considered in similar cases after assessing risk and benefits for individual cases.