A case-control study addressing the population of epidermal and dermal inflammatory infiltrate including neural milieu in primary prurigo nodularis using S-100 and toluidine blue stain and its therapeutic implications

BACKGROUND

The pathogenesis of prurigo nodularis (PN) is considered to be multifactorial, with numerous cells and cytokines confabulating to produce an aberrant immune response.

METHODS

A cross-sectional observational study was done in cases of untreated primary prurigo nodularis cases with histopathological assessment in 49 cases from lesional and nonlesional skin with assessment of epidermal and dermal changes, dermal infiltrate, S-100 and toluidine blue staining to assess the expression of nerve and mast cells.

RESULTS

The most common histological changes seen in lesional skin were hyperkeratosis (98%), irregular hyperplasia (69.4%), hypergranulosis (69.4%), subepidermal clefting (6%), vertical collagen bundles (51.0%), and dermal fibrosis (48.9%). Chronic inflammatory infiltrate was seen in all cases (100%) predominantly of lymphocytes (100%) followed by eosinophils (18.4%), plasma cells (8.2%), and neutrophils (2.0%). There was a marked increase in the expression of S-100 (6.92 ± 3.40 vs. 3.94 ± 2.15, P < 0.001) and toluidine blue (4.99 ± 4.47 vs. 1.22 ± 1.28, P < 0.001) in the lesional skin as compared to the nonlesional skin.

CONCLUSION

We can infer that the epidermal and dermal pathology in PN is related to the infiltrate of lymphocytes, mast cells, and neural hyperplasia which perpetuate the pathogenesis by triggering the itch-inflammation cycle. Thus, apart from immunosuppressive agents that target lymphocytes and their cytokines, therapy targeted at mast cells and neural proliferation may be needed to treat prurigo nodularis.

Long-term lead and mortality following pacemaker and defibrillator implantation in adult congenital heart disease

Background

Adult congenital heart disease (ACHD) survival has dramatically improved in recent decades. As such, clinicians now face the complex long-term interactions of congenital and chronic heart diseases. One area of continuing mortality in this group is arrhythmias, especially in those with cardiovascular implantable electronic devices (CIEDs). With these developments in survival, the long-term outcomes of the CIED systems and their effects on mortality are beginning to be elucidated.

Aims

This study aims to compare the effects of system location, surgical history, patient demographics and congenital disease complexity on lead survival, complication distributions and patient mortality in ACHD CIED patients.

Methods

A retrospective cohort of 250 ACHD CIED patients with follow up at a heart centre was collated from clinical correspondence letters and CEID records. Data was collected on demographics, mortality and lead survival and complications. Survival data was analysed with Kaplan-Meier (KM) curves and hazard ratio tests.

Results

Complex ADHD patient survival was less than the non-complex cohort (HR 0.38, 95% CI 0.22–0.67, p&lt;0.01). Lead survival was longer in non-surgical patients (HR 1.42, 95% CI 1.13–1.78, p&lt;0.01) and longer in female patients (HR 1.35, 95% CI 1.07–1.69, p&lt;0.01) (Figure 1). No significant differences in mortality or lead survival were seen between epicardial and transvenous systems.

Conclusions

Complex ACHD is associated with worse patient mortality in CEID patients. Surgical history and male gender are associated with worsened lead survival.

Funding Acknowledgement

Type of funding sources: None.

Effect of Different Itraconazole Dosing Regimens on Cure Rates, Treatment Duration, Safety, and Relapse Rates in Adult Patients With Tinea Corporis/Cruris: A Randomized Clinical Trial

Importance

With worldwide emergence of recalcitrant and resistant dermatophytosis, itraconazole is increasingly being used as the first-line drug for treatment of tinea corporis/cruris (TCC). Apparent inadequacy with low doses has led to empirical use of higher doses and antifungal combinations.

Objective

To compare cure rates, treatment durations, safety profiles, and relapse rates of itraconazole 100, 200, and 400 mg/d for the treatment of TCC.

Design, Setting, and Participants

This double-blind randomized clinical trial included adult patients with treatment-naive TCC involving at least 5% body surface area. Patients were recruited from the dermatology outpatient department of a tertiary care hospital in New Delhi, India between March 1, 2020, and August 31, 2021.

Interventions

Patients were randomized to 1 of the 3 treatment groups. Biweekly blinded assessments were performed until cure or treatment failure. Posttreatment follow-up of at least 8 weeks was conducted to detect relapses.

Main Outcome and Measures

Cure rates, treatment durations, safety profiles, and relapse rates were assessed. Secondary outcomes included comparison of rapidity of clinical response and cost-effectiveness between groups.

Results

Of the 149 patients assessed, the mean (SD) age was 34.3 (12.2) years, 69 patients (46.4%) were women, and 80 patients (53.6%) were men. The difference in cure rate between the 100- and 200-mg groups was statistically nonsignificant (hazard ratio [HR], 1.44; 95% CI, 0.91-2.30; P = .12), while the difference between the 100- and 400-mg groups (HR, 2.87; 95% CI, 1.78-4.62; P < .001) and between the 200- and 400-mg groups (HR, 1.99; 95% CI, 1.28-3.09; P = .002) was statistically significant. Mean (SD) treatment durations were statistically significantly different between the 100- and 400-mg groups (7.7 [4.7] weeks vs 5.2 [2.6] weeks; P = .03) and between the 200- and 400-mg groups (7.2 [3.8] weeks vs 5.2 [2.6] weeks; P = .004), but the difference between the 100- and 200-mg groups was not statistically significant. A total of 55 patients (47.4%) relapsed after treatment. Relapse rates were comparable across groups. No patient discontinued treatment due to adverse effects. Treatment with the 200-mg dose incurred a 63% higher cost and 400 mg a 120% higher cost over 100 mg in achieving cure.

Conclusions and Relevance

In this randomized clinical trial, high overall efficacy was observed among the 3 itraconazole doses for treatment of TCC, but with prolonged treatment durations and considerable relapse rates. Treatment with the 200- and 100-mg doses did not differ significantly in efficacy or treatment durations, while 400 mg scored over the other 2 on these outcomes. Considerable additional cost is incurred in achieving cure with the 200- and 400-mg doses.

Trial Registration

Clinical Trials Registry of India Identifier: CTRI/2020/03/024326.

Correlation of Periodontal Status and Salivary Flow in Patients with Oral Submucous Fibrosis in Central India Population: A Study Protocol

Background: One of the commonest premalignant condition is Oral Submucous Fibrosis. The main etiology is consumption of areca nut and its products which leads to reduced mouth opening (Trismus) and reduction in the salivary flow (Xerostomia). Both these conditions eventually result in periodontal destruction. Objectives: The purpose of this research is to see if there is a link between periodontal health and salivary flow in OSMF patients. Methodology: 50 patients each clinically diagnosed as chronic periodontitis with and without OSMF will be enrolled in test and control group respectively. Plaque Index, Papillary Bleeding Index, Probing Pocket Depth, Clinical Attachment Loss (CAL), Gingival Recession (REC) will be compared in both the group for assessment of the result. Saliva that has not been stimulated will be collected using a funnel in a calibrated beaker in both the groups. Results: Patients with OSMF and chronic periodontitis will have reduced salivary flow and a compromised periodontal status whereas chronic periodontitis patients without OSMF will have normal salivary flow and comparatively less periodontal destruction. Conclusion: OSMF is precancerous condition which leads to xerostomia and may result  in periodontal destruction and therefore OSMF condition should be identified and treated as early as possible.

Predicting a therapeutic cut-off serum level of itraconazole in recalcitrant tinea corporis and cruris-A prospective trial

BACKGROUND

With rising resistance to terbinafine, and consistently high MICs to fluconazole and griseofulvin, itraconazole is being increasingly used as a first line drug for tinea corporis/cruris. However, inadequate clinical responses are often seen with it in spite of in vitro susceptibility. This is possibly related to a variable pharmacokinetic profile of itraconazole. The drug serum levels associated with the therapeutic outcome have not been defined in dermatophytic infections.

METHODS

Forty treatment naïve patients with tinea corporis/cruris were randomised to one of the three dose groups (100, 200 and 400 mg/day) of itraconazole. The drug serum levels of 21 of these patients were obtained after 2 weeks of treatment and correlated with the final clinical outcome and in vitro antifungal susceptibility data.

RESULTS

Trichophyton indotineae was identified by sequencing of ITS region of rDNA and TEF1α. All isolates were sensitive to itraconazole (Minimum Inhibitory Concentration (MICs) range: 0.06-0.5 µg/ml), while MICs to terbinafine were uniformly high (range 8-32 µg/ml). Thirty-seven patients (92.5%) achieved complete cure, while three failed treatment. Serum levels achieved with 400 mg/day were significantly higher than levels with 100 or 200 mg dose. All patients with itraconazole serum levels of >0.2 µg/ml were cured, while two out of the 10 patients with serum levels <0.2 µg/ml failed treatment.

CONCLUSIONS

Therapeutic failures are uncommon with itraconazole, and the prevalent strain in India has low itraconazole MICs. Treatment failure is likely with itraconazole serum levels of <0.2 µg/ml, while levels >0.2 µg/ml are consistently associated with a positive therapeutic outcome.

The Impact of COVID-19 on General and Dental Health

COVID-19 (Coronavirus disease 2019) is a contagious infection caused by novel coronavirus SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). This novel virus was publicly announced as an infectious pathogen by the “Chinese Centre for Disease Control and Prevention” on 8 January 2020. The World Health Organization named COVID-19 a pandemic crisis all over the world on March 11, 2020. Aged people and medically compromised people like patients with diabetes, cardiovascular disease, chronic respiratory disease, and cancer are the vulnerable populations for developing an illness. A guideline has been postulated and described in the form of a journey map to avoid exposure of dental health care professionals to COVID-19. This review provides a comprehensive outlook for the current pandemic situation, its origin, spread, and preventive measures to be utilized in general and in dental practice.

An uncommon variant of erythema nodosum leprosum responding well to methotrexate: Report of two cases

Reactions in leprosy are acute inflammatory episodes that can be classified as type I or type II. Recognition and timely management of these patients is critical to avoid permanent disability. We present two cases of erythema nodosum leprosum, presenting with recurrent atypical features, responding well to a low dose of methotrexate.

Reference Charts of Fetal Biometric Parameters at Different Gestational Age Groups in Indian Population

To develop, a reference charts of fetal abdominal circumference and femur length in normal pregnant women by using ultrasonography for Indian population. Further comparison of our findings with data derived from different population. This retrospective cross-sectional study included 300 normal singleton pregnancies and was carried out in the department of Anatomy, All India Institute of Medical Sciences, Jodhpur (Rajasthan), India from September 2017 to April 2019. Ultrasonography measurements included Abdominal circumference (AC) and Femur length (FL). Reference charts with mean AC and FL for corresponding Gestational age (GA) in weeks were developed. Also reference centiles (10th, 50th, 90th and 95th) were derived from this model and compared with similar studies done on different population. There was no statistically significant difference in age distribution of pregnant women (p=0.87). Both AC and FL were found to have statistically significant linear relationship with advancing gestational age (p=0.0005 & p=0.0003 respectively). There is significant difference observed between the values obtained in present study with studies concluded on Chinese and European population. Measurement of AC and FL are used to predict gestational age of fetus by using various regression formulae, also AC is known to be good predictor of nutritional status of fetus in utero. A separate chart is required for every different population because ethnicity, nutrition and environmental factor can have impact on normal values. Therefore, a reference chart for these parameters according to Indian population standards is essential to avoid misinterpretation of data. This would help to avoid misdiagnosis of intrauterine growth retardation or macrosomia during prenatal and perinatal period.

A prospective study examining the effect of selected topical and systemic drugs on pruritus grading system score and stat 6 expression in patients of prurigo nodularis

Background:

Prurigo nodularis (PN) is a chronic dermatologic condition presenting as multiple papulonodular lesions occurring with intense pruritus. Though numerous agents (topical, systemic, phototherapy and biological drugs) have been tried, the outcomes are variable.

Objectives:

The aim of this study was to assess the role of topical and systemic therapies in primary PN by comparing the Pruritus Grading System (PGS) score at baseline and 1 month post-therapy.

Materials and Methods:

Of 86 diagnosed cases of PN, 49 cases of primary PN were clinically graded by Pruritus Grading System Score (PGSS), and assessed histopathologically by IHC staining (STAT-1, 3, and 6). Apart from topical agents, oral nortriptyline (mild grade), methotrexate (moderate grade) and thalidomide (severe grade) were administered, whereas doxepin was administered for itching. The PGSS was assessed after 1 month of therapy.

Results:

Among 49 patients of PN, the majority of patients showed a significant decrease in PGSS (P = <0.001) in 1 mont, which correlated with STAT-6 expression. The combination of different topical and oral agents resulted in a statistically significant change in severity, though individual drugs did not achieve statistically significant results.

Conclusion:

A combination of selected oral and topical agents can effectively control the severity of PN within one month, and this was found to correlate with STAT 6 expression.

Combined endovascular and surgical approaches to treat intralobar pulmonary sequestration: a case report

Pulmonary sequestration is a congenital abnormality of a non-functional pulmonary mass with anomalous systemic arterial supply. Surgical resection is the gold standard treatment, but it carries a risk of life-threatening haemorrhage from accidental injury of the anomalous artery. Endovascular embolisation has been introduced as a safe alternative, but does not eliminate the possibility of symptom recurrence. We report a case of a 61-year old woman with intralobar pulmonary sequestration treated with a combination of endovascular coil embolisation and surgical resection.

Complete Remission in a Patient with Treatment Refractory Bullous Pemphigoid after a Single Dose of Omalizumab

Bullous pemphigoid (BP) is an autoimmune disorder known to be mediated by immunoglobulin G (IgG) autoantibodies. The role of immunoglobulin E (IgE) antibodies is being investigated as their presence has been described in severe cases. Herein, we report a patient of BP who was refractory to most conventional agents and developed hypotension after rituximab but achieved lasting remission after a single dose of the anti-IgE monoclonal antibody omalizumab.

Zosteriform multidermatomal nodules and plaques in a case of lepromatous leprosy: an uncommon presentation

Leprosy is caused by the obligate intracellular organism Mycobacterium leprae which mainly affects the skin and nervous system. The course of the disease is determined by host immunity, it is thus believed that in lepromatous leprosy (LL), all manifestations are bilaterally symmetrical. This is because of the inability of the host to mount an adequate cell-mediated immune response, resulting in widespread haematogenous dissemination of bacilli. Varied manifestations of LL have been reported; however, a multidermatomal pattern of nodules is hitherto unreported and we suggest a hypothesis for its presentation.

Cutaneous Histoplasmosis: An Unusual Presentation with Nasal Obstruction

Histoplasmosis is a systemic fungal disease that may be presented with a variety of clinical manifestations, usually as an opportunistic infection in immunocompromised individuals. We present an HIV seropositive patient with a large fleshy growth causing left-sided nasal obstruction, as an unusual presentation. The lesions shrunk dramatically and almost completely on intravenous amphotericin-B lipid complex (ABLC) given for 2 weeks followed by long-term oral itraconazole.

Estimation of Fetal Weight: An Ultrasonography Study in Indian Population

To create a reference chart for estimated fetal weight (EFW) in normal pregnancy for use in Indian population and compare it with reference chart from other population. This retrospective cross-sectional study included 300 normal singleton pregnancies coming for routine antenatal ultrasonography examination and was carried out at All India Institute of Medical Sciences, Jodhpur from September 2017 to April 2019. Ultrasonographic measurements included fetal biparietal diameter (cm), head circumference (cm), abdominal circumference (cm) and femur length (cm). Estimated fetal weight was calculated by using Hadlock algorithm which is already fed into ultrasonography machine. Reference chart with mean EFW for corresponding Gestational age (GA) in weeks was developed. Also Reference centiles (10th, 50th, 90th and 95th) were derived from this model. There was no statistically significant difference in age distribution of pregnant women (p=0.87). Statistically significant linear relationship found between EFW and advancing gestational age (p=0.0004). Maximum gain in EFW (34.05%) was observed after second trimester (28 week). Maximum and minimum fetal weight at 38 weeks of GA in our study found to be 3389 grams and 2567 grams respectively, which has significant difference. This could be due to huge difference in socio-economic and nutritional status among Indian population which might have impacted on maternal and fetal health. Estimated fetal weight was found to be at lower range in Indian population compared to reference chart developed into western population. Fetal weight to their corresponding GA is an important factor in determining growth and development in fetus. In normally developing fetus the EFW has linear correlation with advancing GA. A separate reference chart is required for every different population because ethnicity, nutrition and environmental factor can have impact on normal EFW values. This would help to avoid misdiagnosis of intrauterine growth retardation or macrosomia in fetuses and hence unnecessary medical interventions can be prevented during prenatal and perinatal period.

Monitoring steady production of 1,3-propanediol during bioprospecting of glycerol-assimilating soil microbiome using dye-based pH-stat method

AIM

In this investigation, a dye-based pH-stat method was devised for monitoring steady production of 1,3-propanediol (1,3-PDO) during bioprospecting of glycerol-assimilating soil microbiome.

METHODS AND RESULTS

Soil samples were collected from two potential sites of CSIR-IIP, India. Selective enrichment of microbial consortia was done using the glycerol-based medium at initial stage, followed by purification to isolated colonies, after positive high-performance liquid chromatography detection of 1,3-PDO in the fermentation broth. When the purified isolated were re-tested for 1,3-PDO production, only two isolates namely Isolate 1 and Isolate 3 were capable of producing the targeted product preferably under anaerobic conditions. Based on better 1,3-PDO fermentation efficiency (Isolate 3, 22% vs Isolate 1, 4·48%) and acetic acid as the only major by-product, Isolate 3 was shortlisted for further studies. A dye-based technique was devised in which bromothymol blue was incorporated into the medium to monitor the pH drop due to acetic acid formation and hence change in colour. Visual change in colour helped in intermittent pH restoration. During fermentation, with pH stat being 8-8·5, Isolate 3 at 32°C yielded 0·67 mol mol^-1 1,3-PDO within a short span of 12 h only with an initial concentration of glycerol being 20 g l^-1 . Phylogenetic analysis revealed that Isolate 3 shared 95·8% homology with Citrobacter freundii CFNIH1 and hence designated as C. freundii IIP DR3.

CONCLUSION

This study demonstrated that during bioprospecting glycerol-assimilating microbiome, dye-based technique can be successfully employed. This technique can further be exploited to monitor consistent production of all microbial secondary metabolites that accompanies acid production.

SIGNIFICANCE AND IMPACT OF THE STUDY

Incorporation of 'Bromothymol blue' can visually help in the identification of pH drop in the medium, so that pH stat can be easily maintained during 1,3-PDO production from glycerol especially under shake flask conditions.

Evaluating novel fungal secretomes for efficient saccharification and fermentation of composite sugars derived from hydrolysate and molasses into ethanol

This paper evaluates the ability of secretome from two thermotolerant fungal strains (Aspergillus terreus 9DR and Achaetomium strumarium 10DR) for boosting the hydrolytic efficiency of benchmark cellulolytic preparation (Cellic CTec2). Further we report enhanced saccharification of different agro-residues under semi-aerobic when compared to aerobic conditions. The mass spectroscopic analysis of the hydrolysates indicates the role of auxiliary oxidative enzymes present in A. terreus and A. strumarium secretomes for enhancing the capability of the cellulolytic cocktails. The paper further demonstrate positive effect of using the cocktails for enhanced saccharification and subsequent fermentation to ethanol of acid pre-treated rice straw, corn residues and sugarcane bagasse at higher substrate loading rates (20% w/v). The paper also reports co-utilization of composite sugars derived from molasses and enzymatic hydrolysate obtained from agnostic lignocellulosics for efficient bioconversion to ethanol applicable for developing BOLT-ON technology.

Awareness of Undergraduate Dental and Medical Students Towards Oral Cancer

Oral cancer is a common malignancy in Nepal and many other South East Asian countries, which is predisposed by a variety of potentially malignant oral diseases. Considering the importance of knowledge of health professionals and their role in early diagnosis and reduction of cancer statistics, this study aims to evaluate the awareness of undergraduate dental and medical students towards oral cancer. The study involved undergraduate dental and medical students of BP Koirala Institute of Health Sciences, Nepal. A self-administered questionnaire adapted from Carter to Ogden was distributed. One hundred forty-three dental and 311 medical students responded to the questionnaire. Significantly more dental (80.4 %) than medical students (36.0 %) were found to routinely examine the oral mucosa. Tobacco smoking and chewing were the most commonly recognized risk factors by both medical and dental students. Most of the students found ulcer as the common change associated with oral cancer. Only 30 out of the total students felt very well informed about oral cancer. This study has demonstrated a lack of awareness in some aspects of oral cancer among medical and dental students which highlights the need to frame new teaching methodologies. Similar studies from other health institutions would provide an insight regarding the same and could be a base for formulating a uniform curriculum in the implementation of knowledge regarding oral cancer.

Higher infliximab trough levels are associated with perianal fistula healing in patients with Crohn's disease

BACKGROUND

Infliximab has been found to be efficacious in the treatment of fistulas in the setting of Crohn's disease, even though some patients do not benefit from therapy.

AIM

To assess the correlation between perianal fistula healing and trough levels of infliximab.

METHODS

In this cross-sectional study, we identified patients with Crohn's disease who had perianal fistulas and were treated with infliximab for at least 24 weeks. We excluded patients who underwent a faecal diversion procedure or proctectomy. Predictive variables included demographics, disease phenotype, disease activity, infliximab levels, anti-infliximab antibodies. The primary outcome was fistula healing defined as the absence of drainage. The secondary outcome was complete fistula closure and mucosal healing.

RESULTS

117 patients were included. Patients with fistula healing had significantly higher median serum infliximab levels when compared to those with active fistulas [15.8 vs. 4.4 μg/mL, respectively (P < 0.0001)]. There was an incremental gain in fistula healing with higher infliximab levels. The AUC for the association between fistula healing and infliximab levels was 0.82 (P < 0.0001), while the AUC for the association of infliximab levels and fistula closure was 0.69 (P = 0.014). Patients with anti-infliximab antibodies had a lower chance of achieving fistula healing (OR: 0.04 [95%CI: 0.005-0.3], P < 0.001).

CONCLUSIONS

There is a significant association between serum infliximab levels and rates of fistula healing. Achieving infliximab levels ≥10.1 mcg/mL in patients with Crohn's disease and perianal fistulas may improve outcomes as part of a treat-to-target strategy.

The toxic effects of sodium fluoride on the reproductive system of male rats

The present study was undertaken to evaluate the effect of fluoride toxicity on the reproductive system of male rats. Sexually mature male Wistar rats were exposed to 2, 4, and 6 ppm sodium fluoride in their drinking water for 6 months ad libitum. Sperm motility and density in cauda epididymis were assessed. Biochemical and histological analysis were performed in reproductive organs. Fluoride treatment brought about a significant decrease in the weight of testis, epididymis, and ventral prostate. The sperm motility and density were significantly reduced. There was a marked reduction in the number of primary spermatocyte, secondary spermatocyte, and spermatids. The Sertoli cell counts and their cross sectional surface areas were significantly decreased. The Leydig cell nuclear area and the number of mature Leydig cells were also significantly decreased. The protein content of the testis and epididymis were significantly reduced. Fructose in the seminal vesicles and cholesterol in testes were increased significantly. In conclusion, sodium fluoride administrated in drinking water of 2, 4, and 6 ppm concentration for 6 months to male rats adversely affected their fertility and reproductive system.

A comparative study of central versus posterior approach for internal jugular hemodialysis catheter insertion

Internal jugular (IJ) catheter insertion for hemodialysis (HD) is an indispensable procedure in the management of patients with renal failure. The central approach is favored over posterior approach to insert IJ catheters. There are no studies comparing the outcomes between the two approaches. The aim of this study was to compare central approach with posterior approach for IJ HD catheter insertion and to analyze various outcomes like procedure-related complication rates, catheter insertion failure rates, interruptions during dialysis due to blood flow obstruction and catheter infection rates between the two methods among patients receiving HD. All patients requiring IJ HD catheter insertion during a 1-month period were randomly assigned to undergo catheter insertion via either conventional central approach or posterior approach. Patients were followed-up till the removal of the catheter. Among 104 patients included in the study, 54 were assigned to the central approach group and 50 to the posterior approach group. The central approach group had higher rate of procedure-related complications (14.81% vs. 6%, P = 0.04). Catheter insertion failure rates were marginally higher in posterior approach group (20% vs. 12.96%, P = 0.07). One or more instance of interruption during HD due to obstruction in blood flow was more common in posterior approach (46% vs. 9.25%, P < 0.01). Catheter infection rates were similar between the two groups; 16.66% (n = 9) in central group vs. 14% (n = 7) in posterior group. Posterior approach is a reasonable alternative to conventional central approach in IJ cannulation for HD catheter. It is, however, associated with a significantly high rate of interruption in HD blood flow and catheter insertion failure rates. The posterior approach can be used in patients with local exit site infection or in failed attempts to cannulate IJ vein via the conventional central approach.

Periodic Peritoneal Dialysis in End Stage Renal Disease: Is it Still Relevant? A Single Center Study from India

BACKGROUND

High cost of maintenance hemodialysis (HD) and continuous ambulatory peritoneal dialysis (PD) in India has made renal replacement therapy out of reach of many patients with end stage renal disease (ESRD). Repeated puncture PD although inferior to HD biochemically, is easily and freely available across Rajasthan, India, and is simple to perform, and does not require sophisticated machines, thus making it an attractive option for dialysis for ESRD.

AIM

To analyze the outcomes of periodic PD in patients with ESRD requiring dialysis support.

SUBJECTS AND METHODS

A prospective study analyzing the data of patients who underwent PD between August 2010 and January 2013 in Sawai Man Singh Hospital, Jaipur, India was conducted. Patients were divided into three groups based on the time period between first and second session of PD. Detailed demographic and clinical data during the study period were collected along with PD related complications. The main outcome studied was technique survival 1 year post initiation of PD.

RESULTS

234 patients received an initial session of PD, of which 174 had a good response and were included in the study. 19 patients received the second PD within 7 days of first (Group 1), 45 patients within 8-14 days (Group 2) and 110 patients within 15-21 days (Group 3). The overall 1 year technique survival was 68.4% (91/133), with a rate of 50% (5/10), 56.8% (21/37), and 75.6% (65/86) for Group 1, Group 2, and Group 3, respectively. The time duration between first and second PD proved to be reliable indicator of the subsequent response, with a technique survival rate significantly lower in Group 1 patients compared to Groups 2 and 3 (P = 0.04). Median dialysis free days were 11, 16 and 21 days in Group 1, Group 2, and Group 3, respectively. Peritonitis rate observed was 2.1% (49/2261) during the study period.

CONCLUSION

Periodic PD is a simple, safe and cheap procedure, which can be considered as used as a palliative measure in terminal uremia in underprivileged areas.

Use of Iron Chelating Agents in Transfusion Dependent Thalassaemia Major Patients

This cross-sectional study was done to find and investigate the utilization pattern of iron chelating agents among 73 transfusion-dependent thalassaemia major patients with continuous enrolment for at least 1 year in a day care treatment centre run by The Thalassaemia Society of India, Kolkata from November 2014 to January 2015. Transfusion dependent thalassaemia major patients above the age of 2 years managed by various haematologists and Thalassaemia specialists were studied. The administration of iron chelators namely Desferrioxamine (DFO), Deferiprone (DFP) and Deferasirox (DFX) were evaluated. Forty seven (64%) of the thalassaemics had serum ferritin level below 2500 ng/dl, of whom 20(27%) patients have ferritin level below 1000ng/dl. A number of 55(75%) of 73 patients who were treated with a single chelating agent consisted 50 patients only on DFX. Exact 8(67%) patients were on DFO+DFP and 4(33%) are treated with DFX+DFP. The mean age was 19 and mean serum ferritin level was 2280 ng/dl among the thalassaemia major patients. DFX was used 68% of patients as monotherapy and 5% patients in combination therapy with DFP. DFX in the dose of 30-40 mg/kg/day was prescribed in 52% of patients. Mean dose of 15 mg/kg/day of DFX was been administered in combination with DFP (75 mg/kg/day) in 5% patients. DFO+DFP were preferred by 8 patients, out of which 6 were aged above 25. Cost of monotherapy is twice that of combination therapy. These data demonstrates the ferritin status and present scenario of utilization of chelating agents among thalassaemia major patients on repeated transfusions. The dosing of new drug, Deferasirox and the cost analysis of various chelating regimen has also been dealt. Individualization rather than rationalization of chelation therapy should be focussed upon in managing iron overload in thalassaemia.

Morphometry and variations of the human suprascapular notch

AIM

The present study proposes a simple method to study variations in shape and dimensions of suprascapular notch, to classify different types and subtypes of notch and to measure the thickness of superior transverse scapular bar (ossified superior transverse ligament of scapula).

MATERIAL AND METHODS

Seven hundred and twenty-eight dried scapulae were observed, examined and studied in detail. Scapulae with suprascapular notch, with suprascapular foramen having varying degree of ossification in the form of transverse scapular bar were included in the present study. Measurements of suprascapular notch and superior transverse scapular bar were taken with the help of digital vernier calliper and recorded in millimetres. The superior transverse diameter, inferior transverse diameter, depth, maximum thickness of suprascapular notch and thickness at lateral and medial end of transverse scapular bar, mean thickness of superior transverse scapular bar were recorded. The data was analyzed statistically.

OBSERVATIONS AND RESULTS

We observed five types of notch in scapulae, type I: without a discrete notch (ill defined), 25 (3.43%); type II: a "V" shaped notch, 192 (26.37%); type III: "U" shaped notch, 383 (52.60%); type IV: inverted "V" shaped notch, 28 (3.84%); type V with absent suprascapular notch: 6 (0.82%). Type II and type III were again subclassified into subtypes (a, b, c and d) on the basis of depth of notch. Scapulae with superior transverse scapular bar (n=94, 12.91%) were classified according to variation in mean thickness of transverse scapular bar (MTSB).

CONCLUSION

This study will help clinicians to correlate suprascapular nerve entrapment with a specific type of suprascapular notch and notch with ossified transverse scapular ligament.

Cytological Diagnosis of Primary Thyroid Tuberculosis

Primary thyroid tuberculosis is an extremely rare disease, even in countries where other forms of tuberculosis are abundant. TT has no age bar but usually affects women in fourth and fifth decade. Hereby, we report a case of 16-years-old girl presented with complaint of progressively increasing, painful thyroid swelling. Diagnosis of TT was made on cytology and there was no evidence of involvement of any other organ by tuberculosis. Despite of its rarity, TT is usually misdiagnosed. So, a clinician should always consider this entity in the differential diagnosis of thyroid swelling. Fine needle aspiration cytology is the best diagnostic method and can result in the avoidance of unnecessary thyroid surgeries.

Morphometric analysis and anatomical variations of infraorbital foramen: a study in adult North Indian population

PURPOSE

Various studies have been conducted on morphometric variations of infraorbital foramen to provide data to surgeons for nerve block in infraorbital region. This study aims to analyse the anatomical variations by comparing various morphometric measurements of infraorbital foramen in dry skulls of adult North Indian population. This study becomes relevant in the present study group as very scant data is available about the variations and morphometric measurements in Indian population. The data thus collected can be standardized and become useful for the surgeons working in this area of face.

MATERIALS AND METHODS

The study was conducted on 75 dry adult human skulls, which were a part of Department of Anatomy, used for teaching purposes in medical colleges. Straight distance of the Infraorbital foramen from the infraorbital rim, supraorbital foramen and sagittal plane was measured. The position of the infraorbital foramen was determined in relation to maxillary teeth and supraorbital foramen. The data thus obtained was analysed.

RESULTS

The distance of infraorbital foramen from infraorbital rim, supraorbital foramen, sagittal plane in the present study was found to be 6.71 ± 1.11 mm, 42.02 ± 4.31 mm and 31.94 ± 4.88 mm respectively. The position of infraorbital foramen was lateral in relation to supraorbital foramen (in 88% of cases). Infraorbital foramen was above the 1st premolar tooth in most of the cases. Accessory infraorbital foramen was found in 11.2% cases (double foramen).

CONCLUSION

The data thus obtained will perhaps be helpful to the surgeons in identifying the extent of the operative field thereby reducing procedural risks.