vishnu senthil - Academia.edu (original) (raw)
Papers by vishnu senthil
International journal of orthopaedics sciences, 2024
Vitamin D supplementation plays a crucial role in managing Rheumatoid Arthritis (RA) by modulatin... more Vitamin D supplementation plays a crucial role in managing Rheumatoid Arthritis (RA) by modulating the immune response, reducing inflammation, and maintaining bone health. Research suggests a clear association between low vitamin D levels and increased disease activity in RA patients. As indicates, addressing vitamin D deficiency is paramount in preventing bone-related complications and improving overall health outcomes in RA. While the benefits of vitamin D supplementation in RA are promising, optimal dosage and duration of supplementation remain subjects of debate. Personalized treatment strategies based on individual patient factors are essential for effective management. Future research directions should focus on larger clinical trials to determine precise dosages and explore potential combination therapies to enhance RA management. Collaborative efforts among healthcare professionals and researchers are critical to establishing definitive guidelines for clinical practice in this field. Conclusion: In conclusion, the role of Vitamin D in Rheumatoid Arthritis (RA) is essential for managing disease progression and symptoms effectively. Research consistently demonstrates the impact of Vitamin D deficiency on increased disease activity in RA patients, highlighting the significance of maintaining adequate levels of this crucial nutrient. Vitamin D supplementation has the potential to modulate the immune response, reduce inflammation, and support bone health, offering promising benefits for RA management. However, optimal dosage and duration of supplementation remain subjects of debate, emphasizing the need for standardized guidelines and personalized interventions. Continued research efforts are necessary to determine the most effective strategies for incorporating Vitamin D supplementation into RA treatment protocols, considering individual patient characteristics and potential interactions with other medications. Collaborative approaches among healthcare professionals and researchers are crucial for advancing our understanding of the intricate relationship between Vitamin D and RA, ultimately optimizing patient outcomes and quality of life.
International journal of orthopaedics sciences, 2024
Hyperuricemia is a metabolic condition associated with various health complications, including go... more Hyperuricemia is a metabolic condition associated with various health complications, including gout, kidney disease, and cardiovascular events. Topiroxostat and febuxostat are two commonly prescribed xanthine oxidase inhibitors for managing hyperuricemia, yet there is a paucity of direct comparative studies evaluating their efficacy and safety profiles. To address this gap, we conducted a prospective, randomized, open-label, parallel-group trial involving 50 patients diagnosed with hyperuricemia. Patients were randomly assigned to receive either topiroxostat or febuxostat for a duration of 12 weeks. Primary outcome measures included changes in serum uric acid (SUA) levels, while secondary outcomes encompassed renal function parameters and incidence of adverse events. Our findings indicate that both topiroxostat and febuxostat effectively reduced SUA levels over the treatment period, with no significant difference observed between the two groups. However, topiroxostat demonstrated a more significant reduction in serum creatinine levels, urinary albumin excretion, and improvement in estimated glomerular filtration rate (eGFR) compared to febuxostat. Safety profiles were favorable for both medications, with no serious adverse events reported. These results suggest that while both topiroxostat and febuxostat are effective in lowering SUA levels, topiroxostat may offer additional renal protective benefits. Further comparative studies are warranted to elucidate the clinical implications and optimal use of these medications in hyperuricemia management.
Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disorder that causes significant p... more Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disorder that causes significant physical disability, and it affects women three times more commonly than men. It is often seen in their childbearing years. Data on the annual incidence of the disease also suggests a very high percentage in the child-bearing age group. So understanding their problems and finding a solution will be critical for a health care professional taking care of them. Decisions about parenthood also become challenging, as they are affected by perceptions of their disease state, health care needs, and complex pharmacological treatments. There is undoubtedly a clear need to support these vulnerable women through this important period of their lives. The management of RA has revolutionized in recent years. The availability of novel therapies, such as biological agents and treatment paradigms, has substantially improved treatment outcomes for patients with RA. Unfortunately, data on the safety of many of these medications is limited, and many may be contraindicated during pregnancy and breastfeeding. To stabilize the disease before conception and to modify the drug regime, coordinated and careful planning is needed. Recent studies showed that only 20-40% of patients with RA achieve remission by the third trimester. Although 50% may be considered to have low disease activity, nearly 20% will have worse or moderate-to-high disease activity during pregnancy and may require further therapeutic intervention. Many women commonly report postpartum relapses, making them unable to properly care for themselves and their children. A lot of women can find it difficult to access information that could help them plan for pregnancy, lactation, and early parenting concerning their chronic conditions. The accessibility and variety of the pharmacotherapeutic agents support disease control optimization before conception and contribute to the success of the female raising of children, but they should be provided with a detailed understanding of their risks and safety in the setting of pregnancy and breastfeeding. It is a hard nut to crack for healthcare providers to use individualized treatment plans not only for treating active disease but also for maintaining disease www.jchr.org
Indian Journal of Orthopaedics, Jan 8, 2024
Journal of foot & ankle surgery, Dec 29, 2023
Achilles tendon is the thickest and strongest tendon and is only found in humans; it evolved as a... more Achilles tendon is the thickest and strongest tendon and is only found in humans; it evolved as a result of bipedal gait. 1 Achilles is a common tendinous lesion affecting 18 in 100,000. The ability to run is a feature present in humans where the spring-like tendon reduces the cost of energy during transport. Tendo-Achilles lesions >4 weeks are termed chronic lesions. Causes of chronic Achilles tendon lesion include neglected spontaneous rupture and failed repair. Spontaneous rupture occurs at 2-6 cm proximal to insertion because of the small cross-section of the tendon and limited vascular supply.
Malaysian Orthopaedic Journal
A 55-year-old women was diagnosed with Baker's cyst and underwent open Baker's cyst excision. She... more A 55-year-old women was diagnosed with Baker's cyst and underwent open Baker's cyst excision. She had developed acute pulmonary embolism in the post-operative period. Our case report is to emphasise the sub-clinical concomitant deep vein thrombosis with Baker's cyst. Such a fatal complication has not been reported in literature and preventive measures of pre-operative venous Doppler and post-operative thrombo-prophylaxis can prevent them.
Journal of Orthopedics and Joint Surgery
SyStematic review material, liquid-like plastic/polymers, or metals are used by the printer to as... more SyStematic review material, liquid-like plastic/polymers, or metals are used by the printer to assemble the model. 3D printing incorporates adding or removing material layers to form the desired shape, which allows porous and solid sections to combine to offer optimal strength and performance. 3D printing application in arthroplasty includes detailed preoperative planning, including the manufacturing of patient-specific templates and cutting guide generation of customized implants. It also increases the accurate guidance to perform desired bone cuts in the arthroplasty. Various studies have been done to validate the outcome of this technology in arthroplasty procedures of different joints in the body.
Journal of orthopaedic case reports, 2023
Scholars academic journal of biosciences, Feb 18, 2023
Original Research Article Knee osteo-arthritis increases the global burden and adds morbidity to ... more Original Research Article Knee osteo-arthritis increases the global burden and adds morbidity to the patient. Total knee replacement is on the rise with patients presenting at stage of advanced knee arthritis increasing surgical morbidity on the patient. Knee cartigram, helps to diagnose early cartilage damage with normal knee radiographs. Addressing cartilage loss at an early stage can preserve the innate knee delaying the onset of arthritis and prevent knee replacement.
Journal of Orthopaedic Association of South Indian States
Plasmablastic lymphoma is a rare aggressive malignancy of B cell origin. Commonly the nasal and P... more Plasmablastic lymphoma is a rare aggressive malignancy of B cell origin. Commonly the nasal and Paranasal regions are involved in HIV positive individuals. We report a retro positive individual presenting with a swelling over the right leg. Clinical and radiological investigations suggested the swelling arising from the extensor digitorum longus (EDL). Differential diagnosis of Rhadomyosarcoma and schwanomma considered after clinico-radiological evaluation. Plasmablastic lymphoma was diagnosed after biopsy and IHC marker analysis. Plasmablastic lymphoma though common in retro-positive patients, arising from the muscle is uncommon. An aggressive tumour of poor prognosis, delay in its diagnosis and treatment because of its uncommon location can cause rapid spread of tumour and death of patient. In our report we want to create awareness to the treating clinician and pathologist that swellings arising from uncommon site in HIV positive individual should be evaluated to rule out plasmabl...
Gazi Medical Journal, 2017
Spontaneous non-traumatic rupture of Tendo-Achilles (TA) as a presenting feature of alkaptonuria ... more Spontaneous non-traumatic rupture of Tendo-Achilles (TA) as a presenting feature of alkaptonuria is unusual. In this disorder, there is deposition of homogentisic acid in the cartilage of major joints and intervertebral disc is responsible for the degenerative changes. Infrequently, it also gets deposited in major tendons that renders them structurally weak ensuing in pathological ruptures. A case is presented with non-traumatic TA rupture and its surgical management in alkaptonuria.
Biomedical Journal of Scientific & Technical Research, 2017
Periosteal osteosarcoma is a rare surface osteosarcoma. It has a benign course with good prognosi... more Periosteal osteosarcoma is a rare surface osteosarcoma. It has a benign course with good prognosis. We report a case of periosteal osteosarcoma in an old lady arising around the elbow and mimicking like synovial sarcoma with calcification in the periarticular tissue. The mass biopsied proved osteosarcoma with osteoid matrix. Patient underwent definitive treatment and followed up for five years with no evidence of recurrence.
Case Study and Case Report, 2016
The Southeast Asian Journal of Case Report and Review, 2016
International journal of scientific research, 2016
Tibialhemimelia is a rare congenital anomaly which is characterized by an aplastic or h... more Tibialhemimelia is a rare congenital anomaly which is characterized by an aplastic or hypoplastic tibia. This condition actually represents a spectrum of anomalies, ranging from total absence of to mild hypoplasia of tibia. We describe a varied presentation of jones type 4 tibialhemimelia with deformed split foot. To our best knowledge such a deformed association has not been reported before.
Journal of Foot and Ankle Surgery (Asia Pacific), 2017
Patients presenting with prolonged ankle pain following trivial trauma should be clinically and r... more Patients presenting with prolonged ankle pain following trivial trauma should be clinically and radiologically investigated. We present two young adults with incidentally diagnosed lytic lesion of talus. They underwent extended curettage and biopsy. Histopathological examination proved as aneurysmal and simple bone cyst and went for a secondary procedure of bone grafting. We want to emphasize the importance of differential diagnosis in the management of lytic lesions and complete removal of tumor. How to cite this article Senthil V, Pandey V, Acharya K. Rare Lytic Lesions of the Talus: A Diagnostic Challenge. J Foot Ankle Surg (Asia-Pacific) 2017;4(1):49-52.
Neurospine, 2018
Paget disease is a metabolic disorder involving abnormal bone turnover that consists of 3 phases:... more Paget disease is a metabolic disorder involving abnormal bone turnover that consists of 3 phases: the initial lytic phase, the intermediate mixed phase, and the chronic sclerotic phase. Paget disease mostly presents as polyostotic or monostotic lesions of the spine, and is rare on the Indian subcontinent. We present a case of isolated Paget disease of the lumbar third vertebra, which was confirmed only at biopsy. The patient presented with chronic low backache with a developing neurological deficit. We managed the patient with posterior spinal stabilisation, using pedicular screws and vertebroplasty of the collapsed vertebrae to regain the height. Upon the diagnosis of Paget disease, the patient was treated with calcitonin and bisphosphonates for 3 months, along with regular monitoring of alkaline phosphatase levels. Through this case, we hope to emphasize that Paget disease should be considered in the differential diagnosis of lytic lesions. Additionally, the alkaline phosphatase level in this patient was high-normal, which was an aspect of the role of Paget disease as a mimicker. Confirmatory biopsy is mandatory in all lesions.
Journal of Evolution of Medical and Dental Sciences, 2016
Synovial sarcoma is a malignant soft tissue tumour rarely involving the bone. We report a case of... more Synovial sarcoma is a malignant soft tissue tumour rarely involving the bone. We report a case of an intraosseous biphasic synovial sarcoma involving the calcaneum. A young adult presented with swelling of left foot with a healed sinus fixed to the bone. Radiological investigation showed the swelling was arising from the bone with infiltration of nearby tissue. No evidence of metastasis or skip lesions. Tissue diagnosis confirmed synovial sarcoma. Patient underwent below-knee amputation with adjuvant chemotherapy. Patient was on remission and later succumbed to the disease due to metastasis to lungs. Very few cases of primary intraosseous synovial sarcoma have been reported.
International journal of orthopaedics sciences, 2024
Vitamin D supplementation plays a crucial role in managing Rheumatoid Arthritis (RA) by modulatin... more Vitamin D supplementation plays a crucial role in managing Rheumatoid Arthritis (RA) by modulating the immune response, reducing inflammation, and maintaining bone health. Research suggests a clear association between low vitamin D levels and increased disease activity in RA patients. As indicates, addressing vitamin D deficiency is paramount in preventing bone-related complications and improving overall health outcomes in RA. While the benefits of vitamin D supplementation in RA are promising, optimal dosage and duration of supplementation remain subjects of debate. Personalized treatment strategies based on individual patient factors are essential for effective management. Future research directions should focus on larger clinical trials to determine precise dosages and explore potential combination therapies to enhance RA management. Collaborative efforts among healthcare professionals and researchers are critical to establishing definitive guidelines for clinical practice in this field. Conclusion: In conclusion, the role of Vitamin D in Rheumatoid Arthritis (RA) is essential for managing disease progression and symptoms effectively. Research consistently demonstrates the impact of Vitamin D deficiency on increased disease activity in RA patients, highlighting the significance of maintaining adequate levels of this crucial nutrient. Vitamin D supplementation has the potential to modulate the immune response, reduce inflammation, and support bone health, offering promising benefits for RA management. However, optimal dosage and duration of supplementation remain subjects of debate, emphasizing the need for standardized guidelines and personalized interventions. Continued research efforts are necessary to determine the most effective strategies for incorporating Vitamin D supplementation into RA treatment protocols, considering individual patient characteristics and potential interactions with other medications. Collaborative approaches among healthcare professionals and researchers are crucial for advancing our understanding of the intricate relationship between Vitamin D and RA, ultimately optimizing patient outcomes and quality of life.
International journal of orthopaedics sciences, 2024
Hyperuricemia is a metabolic condition associated with various health complications, including go... more Hyperuricemia is a metabolic condition associated with various health complications, including gout, kidney disease, and cardiovascular events. Topiroxostat and febuxostat are two commonly prescribed xanthine oxidase inhibitors for managing hyperuricemia, yet there is a paucity of direct comparative studies evaluating their efficacy and safety profiles. To address this gap, we conducted a prospective, randomized, open-label, parallel-group trial involving 50 patients diagnosed with hyperuricemia. Patients were randomly assigned to receive either topiroxostat or febuxostat for a duration of 12 weeks. Primary outcome measures included changes in serum uric acid (SUA) levels, while secondary outcomes encompassed renal function parameters and incidence of adverse events. Our findings indicate that both topiroxostat and febuxostat effectively reduced SUA levels over the treatment period, with no significant difference observed between the two groups. However, topiroxostat demonstrated a more significant reduction in serum creatinine levels, urinary albumin excretion, and improvement in estimated glomerular filtration rate (eGFR) compared to febuxostat. Safety profiles were favorable for both medications, with no serious adverse events reported. These results suggest that while both topiroxostat and febuxostat are effective in lowering SUA levels, topiroxostat may offer additional renal protective benefits. Further comparative studies are warranted to elucidate the clinical implications and optimal use of these medications in hyperuricemia management.
Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disorder that causes significant p... more Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disorder that causes significant physical disability, and it affects women three times more commonly than men. It is often seen in their childbearing years. Data on the annual incidence of the disease also suggests a very high percentage in the child-bearing age group. So understanding their problems and finding a solution will be critical for a health care professional taking care of them. Decisions about parenthood also become challenging, as they are affected by perceptions of their disease state, health care needs, and complex pharmacological treatments. There is undoubtedly a clear need to support these vulnerable women through this important period of their lives. The management of RA has revolutionized in recent years. The availability of novel therapies, such as biological agents and treatment paradigms, has substantially improved treatment outcomes for patients with RA. Unfortunately, data on the safety of many of these medications is limited, and many may be contraindicated during pregnancy and breastfeeding. To stabilize the disease before conception and to modify the drug regime, coordinated and careful planning is needed. Recent studies showed that only 20-40% of patients with RA achieve remission by the third trimester. Although 50% may be considered to have low disease activity, nearly 20% will have worse or moderate-to-high disease activity during pregnancy and may require further therapeutic intervention. Many women commonly report postpartum relapses, making them unable to properly care for themselves and their children. A lot of women can find it difficult to access information that could help them plan for pregnancy, lactation, and early parenting concerning their chronic conditions. The accessibility and variety of the pharmacotherapeutic agents support disease control optimization before conception and contribute to the success of the female raising of children, but they should be provided with a detailed understanding of their risks and safety in the setting of pregnancy and breastfeeding. It is a hard nut to crack for healthcare providers to use individualized treatment plans not only for treating active disease but also for maintaining disease www.jchr.org
Indian Journal of Orthopaedics, Jan 8, 2024
Journal of foot & ankle surgery, Dec 29, 2023
Achilles tendon is the thickest and strongest tendon and is only found in humans; it evolved as a... more Achilles tendon is the thickest and strongest tendon and is only found in humans; it evolved as a result of bipedal gait. 1 Achilles is a common tendinous lesion affecting 18 in 100,000. The ability to run is a feature present in humans where the spring-like tendon reduces the cost of energy during transport. Tendo-Achilles lesions >4 weeks are termed chronic lesions. Causes of chronic Achilles tendon lesion include neglected spontaneous rupture and failed repair. Spontaneous rupture occurs at 2-6 cm proximal to insertion because of the small cross-section of the tendon and limited vascular supply.
Malaysian Orthopaedic Journal
A 55-year-old women was diagnosed with Baker's cyst and underwent open Baker's cyst excision. She... more A 55-year-old women was diagnosed with Baker's cyst and underwent open Baker's cyst excision. She had developed acute pulmonary embolism in the post-operative period. Our case report is to emphasise the sub-clinical concomitant deep vein thrombosis with Baker's cyst. Such a fatal complication has not been reported in literature and preventive measures of pre-operative venous Doppler and post-operative thrombo-prophylaxis can prevent them.
Journal of Orthopedics and Joint Surgery
SyStematic review material, liquid-like plastic/polymers, or metals are used by the printer to as... more SyStematic review material, liquid-like plastic/polymers, or metals are used by the printer to assemble the model. 3D printing incorporates adding or removing material layers to form the desired shape, which allows porous and solid sections to combine to offer optimal strength and performance. 3D printing application in arthroplasty includes detailed preoperative planning, including the manufacturing of patient-specific templates and cutting guide generation of customized implants. It also increases the accurate guidance to perform desired bone cuts in the arthroplasty. Various studies have been done to validate the outcome of this technology in arthroplasty procedures of different joints in the body.
Journal of orthopaedic case reports, 2023
Scholars academic journal of biosciences, Feb 18, 2023
Original Research Article Knee osteo-arthritis increases the global burden and adds morbidity to ... more Original Research Article Knee osteo-arthritis increases the global burden and adds morbidity to the patient. Total knee replacement is on the rise with patients presenting at stage of advanced knee arthritis increasing surgical morbidity on the patient. Knee cartigram, helps to diagnose early cartilage damage with normal knee radiographs. Addressing cartilage loss at an early stage can preserve the innate knee delaying the onset of arthritis and prevent knee replacement.
Journal of Orthopaedic Association of South Indian States
Plasmablastic lymphoma is a rare aggressive malignancy of B cell origin. Commonly the nasal and P... more Plasmablastic lymphoma is a rare aggressive malignancy of B cell origin. Commonly the nasal and Paranasal regions are involved in HIV positive individuals. We report a retro positive individual presenting with a swelling over the right leg. Clinical and radiological investigations suggested the swelling arising from the extensor digitorum longus (EDL). Differential diagnosis of Rhadomyosarcoma and schwanomma considered after clinico-radiological evaluation. Plasmablastic lymphoma was diagnosed after biopsy and IHC marker analysis. Plasmablastic lymphoma though common in retro-positive patients, arising from the muscle is uncommon. An aggressive tumour of poor prognosis, delay in its diagnosis and treatment because of its uncommon location can cause rapid spread of tumour and death of patient. In our report we want to create awareness to the treating clinician and pathologist that swellings arising from uncommon site in HIV positive individual should be evaluated to rule out plasmabl...
Gazi Medical Journal, 2017
Spontaneous non-traumatic rupture of Tendo-Achilles (TA) as a presenting feature of alkaptonuria ... more Spontaneous non-traumatic rupture of Tendo-Achilles (TA) as a presenting feature of alkaptonuria is unusual. In this disorder, there is deposition of homogentisic acid in the cartilage of major joints and intervertebral disc is responsible for the degenerative changes. Infrequently, it also gets deposited in major tendons that renders them structurally weak ensuing in pathological ruptures. A case is presented with non-traumatic TA rupture and its surgical management in alkaptonuria.
Biomedical Journal of Scientific & Technical Research, 2017
Periosteal osteosarcoma is a rare surface osteosarcoma. It has a benign course with good prognosi... more Periosteal osteosarcoma is a rare surface osteosarcoma. It has a benign course with good prognosis. We report a case of periosteal osteosarcoma in an old lady arising around the elbow and mimicking like synovial sarcoma with calcification in the periarticular tissue. The mass biopsied proved osteosarcoma with osteoid matrix. Patient underwent definitive treatment and followed up for five years with no evidence of recurrence.
Case Study and Case Report, 2016
The Southeast Asian Journal of Case Report and Review, 2016
International journal of scientific research, 2016
Tibialhemimelia is a rare congenital anomaly which is characterized by an aplastic or h... more Tibialhemimelia is a rare congenital anomaly which is characterized by an aplastic or hypoplastic tibia. This condition actually represents a spectrum of anomalies, ranging from total absence of to mild hypoplasia of tibia. We describe a varied presentation of jones type 4 tibialhemimelia with deformed split foot. To our best knowledge such a deformed association has not been reported before.
Journal of Foot and Ankle Surgery (Asia Pacific), 2017
Patients presenting with prolonged ankle pain following trivial trauma should be clinically and r... more Patients presenting with prolonged ankle pain following trivial trauma should be clinically and radiologically investigated. We present two young adults with incidentally diagnosed lytic lesion of talus. They underwent extended curettage and biopsy. Histopathological examination proved as aneurysmal and simple bone cyst and went for a secondary procedure of bone grafting. We want to emphasize the importance of differential diagnosis in the management of lytic lesions and complete removal of tumor. How to cite this article Senthil V, Pandey V, Acharya K. Rare Lytic Lesions of the Talus: A Diagnostic Challenge. J Foot Ankle Surg (Asia-Pacific) 2017;4(1):49-52.
Neurospine, 2018
Paget disease is a metabolic disorder involving abnormal bone turnover that consists of 3 phases:... more Paget disease is a metabolic disorder involving abnormal bone turnover that consists of 3 phases: the initial lytic phase, the intermediate mixed phase, and the chronic sclerotic phase. Paget disease mostly presents as polyostotic or monostotic lesions of the spine, and is rare on the Indian subcontinent. We present a case of isolated Paget disease of the lumbar third vertebra, which was confirmed only at biopsy. The patient presented with chronic low backache with a developing neurological deficit. We managed the patient with posterior spinal stabilisation, using pedicular screws and vertebroplasty of the collapsed vertebrae to regain the height. Upon the diagnosis of Paget disease, the patient was treated with calcitonin and bisphosphonates for 3 months, along with regular monitoring of alkaline phosphatase levels. Through this case, we hope to emphasize that Paget disease should be considered in the differential diagnosis of lytic lesions. Additionally, the alkaline phosphatase level in this patient was high-normal, which was an aspect of the role of Paget disease as a mimicker. Confirmatory biopsy is mandatory in all lesions.
Journal of Evolution of Medical and Dental Sciences, 2016
Synovial sarcoma is a malignant soft tissue tumour rarely involving the bone. We report a case of... more Synovial sarcoma is a malignant soft tissue tumour rarely involving the bone. We report a case of an intraosseous biphasic synovial sarcoma involving the calcaneum. A young adult presented with swelling of left foot with a healed sinus fixed to the bone. Radiological investigation showed the swelling was arising from the bone with infiltration of nearby tissue. No evidence of metastasis or skip lesions. Tissue diagnosis confirmed synovial sarcoma. Patient underwent below-knee amputation with adjuvant chemotherapy. Patient was on remission and later succumbed to the disease due to metastasis to lungs. Very few cases of primary intraosseous synovial sarcoma have been reported.