16 Horner Syndrome: Can it be Familial? Case series in a family and review of literature

Ophthalmic literature reveals vague and rare references to Horner syndrome on a hereditary basis. We present a case series of mother and son with Horner syndrome, which was confirmed pharmacologically. They noticed symptoms on the same side at a similar age and no serious pathology was found.Retrospective case review of notes:Case 1: An 11-year-old male presented with 6 week history of anisocoria, mild right ptosis, no heterochromia and no history of trauma or previous surgeries. The anisocoria was more noticeable in the dark, Horner syndrome was confirmed with apraclonidine test.Case 2: Mother of case 1, 50-year-old female diagnosed with right Horner syndrome at the age of 14 in Austria. The presenting features were anisocoria, a lack of sweating on the right side of her face. Diagnosis was reconfirmed pharmacologically.Case 1 was referred to paediatrics for a systemic examination which was normal. He was investigated with urinary catecholamines, MRI head and CT neck and thorax which were all normal. Case 2 was investigated in the past with a normal CT head.Horner syndrome results in the interruption of the oculo-sympathetic pathway and can indicate serious pathology in the head, chest or neck. Our cases demonstrate that familial presentation could indicate an idiopathic aetiology as it is unlikely to have pathological Horner syndrome in two first degree relatives.Our case series highlights the importance of eliciting a family history of Horner syndrome and examining the family members. Positive family history can reassure patients while awaiting results of investigations.

Comparison Between Closed and Open Methods for Creating Pneumoperitoneum in Laparoscopic Cholecystectomy

Background: To study the efficacy of closed and open methods for creating pneumoperitoneum in laparoscopic cholecystectomy by comparing the two in terms of their outcome and complication. Study Design: Single-centre, prospective, observational study. Materials and study: Purposive sampling method where the inclusion criteria were all patients with cholelithiasis who were advised and consented to laparoscopic cholecystectomy of age 18-70 years were included in the study group. Exclusion criteria include patients with a paraumbilical hernia, a history of upper abdominal surgery, uncontrolled systemic illness, and local skin infection. Sixty cases of cholelithiasis satisfying exclusion and inclusion criteria who underwent elective cholecystectomy during the study period were included. Thirty-one of these cases underwent the closed method, while in the remaining 29 patients open method was adopted. Cases in which pneumoperitoneum created by closed technique were grouped as group A and those by open technique as group B. Parameters comparing the safety and efficacy of the two methods were studied. The parameters were access time, gas leak, visceral injury, vascular injury, need for conversion, umbilical port site hematoma, umbilical port site infection, and hernia. Patients were assessed on the first postoperative day, the seventh postoperative day, and then two months after surgery. Some follow-ups were done telephonically. Results: Out of 60 patients, 31 underwent the closed method, while 29 underwent the open method. Minor complications like gas leak during the procedure was observed more in the open method. The mean access time in the open-method group was less than in the closed-method group. Other complications like visceral injury, vascular injury, need for conversion, umbilical port site hematoma, umbilical port site infection, and hernia were not observed in either group during the allocated follow-up period in the study. Conclusion: Open technique for pneumoperitoneum is as safe and effective as the closed technique.

Our Experience with Nasolabial Flaps in Soft Tissue Reconstruction of Oral Malignancy; Feasible Option in Rural Set Up

In this era of microvascular expertise, free flaps are the preferred option by reconstructive surgeons but has technical limitation in rural set up. Nasolabial flaps has been widely mentioned in literature for smaller defect reconstruction with minimal morbidity. It is a robust flap for soft tissue reconstruction in early stage lesion of oral cavity. We present a series of single stage oral cavity reconstruction using inferiorly based islanded nasolabial flaps in small to moderate soft tissue defects. This is a retrospective study which included biopsy proven 10 patients diagnosed with early stage oral cavity malignancy. All the patients underwent single stage islanded nasolabial flap for small to moderate oral defects. Follow up of all patients were recorded with respect to clinical photographs, mouth opening, tongue mobility, deglutition, speech and patient satisfaction. All operated patients had good functional outcome in terms of swallowing, speech and tongue mobility. All patients were satisfactory with the postoperative results. In early stage oral malignancy patients, this option justifies a reliable and cost effective approach. Inferiorly based islanded nasolabial flaps provides a single stage, safer, faster and reliable option for small to moderate oral cavity defects.

Clinical and economic outcomes of continuous glucose monitoring system (CGMS) in patients with diabetes mellitus: A systematic literature review

OBJECTIVE

Poor glycemic management increases the risk of cardiac, microvascular, and other complications. Therefore, timely assessment and control of glycemic levels is paramount in diabetes. Recent advancements in automated management methods is the use of a continuous glucose monitoring system (CGMS). The objective was to study its clinical and economic impact in the glucose level monitoring and how it can be effectively used or reimbursed for wider population.

METHODS

Comprehensive search was done using multiple databases to capture relevant and most recent evidence. All steps were conducted by two independent researchers and discrepancies resolved by a third reviewer. Quality appraisal was performed by relevant scale depending on study design.

RESULTS

Twenty-six and 12 studies were included for clinical and economic outcomes, respectively. Clinical outcomes like HbA1c and glucose variation, time in range, accuracy, etc. were captured. Comparison of different CGMS types was also reported. Major economic outcomes were direct cost, healthcare resource utilization, and work absenteeism.

CONCLUSIONS

CGMS in patients with diabetes is associated with a valuable clinical implications in reducing hypoglycemic events, glucose and HbA1c level. Additionally, it has an impact on direct and indirect costs of management. Further, quantitative analysis would be required to produce concrete evidence.

A GIS-Based Methodology to Determine Effect of Vehicular Pollution at Ward Level: Case Study of Jaipur City

To determine appropriate measures to reduce air pollution in any urban city, the first essential requirement is to estimate the spatial distribution of air pollution parameters in that area. In absence of air monitoring stations, alternative methods are required for the same. In the present work, a GIS-based methodology is presented to estimate the level of NO2 based on the road density of the road network of different categories of roads. Road network GIS layer and measured levels of the average value of NO2 for the year 2019 at 12 air pollution monitoring stations of Jaipur city are used to develop a large number of possible linear regression models for estimation of NO2 values based on road density values. Akaike Information Criterion (AIC) and adjusted r2 values are used to evaluate and arrive at the best-fitted model. Values from the cities of Jodhpur and Kota are used to validate the model. Using this model, NO2 levels are determined at 91 wards of Jaipur city and the output is compared with the similar map derived based on interpolation of NO2 values at the 12 monitoring stations. It is concluded that the methodology developed in this study generates better estimates of NO2 at the ward levels.

Zollinger-Ellison syndrome: an unusual case of chronic diarrhoea in a child

Most cases of Zollinger-Ellison syndrome (ZES) are described in adults. It is a rare disorder in childhood. Most cases present with abdominal pain due to peptic ulceration and chronic diarrhoea not responding to general measures. The symptom complex is initially confused with other more common diseases, which lead to a delay in diagnosis. We present a rare case of a-12-year boy who initially presented with abdominal pain, diarrhoea, vomiting and progressive weight loss for over a two-year period before he was finally diagnosed as a case of ZES with the primary tumour in the pancreatic head and with multiple metastasis in both the liver and lymph nodes.

Histological and immunohistochemical study of estrogen and progesterone receptors in normal human breast tissue in adult age groups vulnerable to malignancy

Analysis of receptor status has become standard procedure for assessing breast cancer patients. Estrogen causes epithelial proliferation in breast tissue via the estrogen receptor (ER). The progesterone receptor (PR) is also regulated by the estrogen gene. Analyzing ER and PR together gives information regarding the likely response of carcinoma patients to hormonal therapy. The aim of the present study was to record the expression patterns of ER and PR in normal mammary tissue in different age groups to provide reference data to facilitate histological diagnosis. Breast tissues from the upper outer quadrant of each side of 27 adult female cadavers were examined after H & E staining. ER and PR were identified and examined by immunohistochemistry. The percentage area occupied by parenchyma relative to stromal tissue was calculated in different age groups and was about 4:6, 3.5:6.5, 3:7, 2:8, and 1.5:8.5 in the 3rd, 4th and 5th, 6th, 7th, 8th and 9th, and 10th decades of life, respectively. Both ER and PR were present in all age groups and the numbers of both receptors were maximal during the 4th decade. The distribution and staining patterns for both ER and PR were recorded in different age groups. The contiguous pattern of ER, which is considered pathognomonic of breast carcinoma, was not seen except in one case in the 6th decade. Moderately stained ER and PR receptor sites predominated throughout. The study of normal breast tissue of similar age might provide comparisons that will help histopathologists to make clinical diagnoses from breast biopsies. Clin. Anat. 29:729-737, 2016. © 2016 Wiley Periodicals, Inc.

Renal Transplantation in the Setting of Prior Urinary Diversion: A Case of Poorly Differentiated Adenocarcinoma in an Ileal Conduit

Though rare, renal transplantation into a bowel containing urinary diversion is necessary in select clinical situations. Compared to renal transplant patients with functional native bladders, patients with urinary diversion have comparable long-term graft and patient survival rates. However, compounding the increased risk of malignancy in those on chronic immunosuppression are the inherent risks of urinary diversion. We present a case report of a high grade adenocarcinoma with neuroendocrine differentiation arising in an ileal conduit and discussion on the pathophysiology, management, and screening of this highly select population.

Construction of a Genetic Linkage Map and Identification of QTLs for Seed Weight and Seed Size Traits in Lentil (Lens culinaris Medik.)

Seed weight and seed size both are quantitative traits and have been considered as important components of grain yield, thus identification of quantitative trait loci (QTL) for seed traits in lentil (Lens culinaris) would be beneficial for the improvement of grain yield. Hence the main objective of this study was to identify QTLs for seed traits using an intraspecific mapping population derived from a cross between L. culinaris cv. Precoz (seed weight-5.1g, seed size-5.7mm) and L. culinaris cv. L830 (seed weight-2.2g, seed size-4mm) comprising 126 F8-RILs. For this, two microsatellite genomic libraries enriched for (GA/CT) and (GAA/CTT) motif were constructed which resulted in the development of 501 new genomic SSR markers. Six hundred forty seven SSR markers (including 146 previously published) were screened for parental polymorphism and 219 (33.8%) were found to be polymorphic among the parents. Of these 216 were mapped on seven linkage groups at LOD4.0 spanning 1183.7cM with an average marker density of 5.48cM. Phenotypic data from the RILs was used to identify QTLs for the seed weight and seed size traits by single marker analysis (SMA) followed by composite interval mapping (CIM) which resulted in one QTL each for the 2 traits (qSW and qSS) that were co-localized on LG4 and explained 48.4% and 27.5% of phenotypic variance respectively. The current study would serve as a strong foundation for further validation and fine mapping for utilization in lentil breeding programs.

Pancreatic extra-gastrointestinal stromal tumour with documentation of C-kit mutation: a case report

Gastrointestinal stromal tumours (GIST) are the most common mesenchymal neoplasms located in the alimentary tract. Stromal tumours that arise outside the gastrointestinal tract as primary tumour are designated as extra-gastrointestinal stromal tumours (EGIST). The EGIST are located in mesentry, omentum, retroperitoneum and rarely in pancreas. Only 19 cases of pancreatic EGIST (pEGIST) have been reported in the literature. Of these, there were only two cases of pEGIST with documentation of molecular alteration in C-Kit gene. We here report a third case of primary pEGIST with documentation of C-kit mutation.

Biosequestration of lead using Bacillus strains isolated from seleniferous soils and sediments of Punjab

The present study was conducted to isolate and explore bacterial strains with a potential to sequester lead (Pb) and tolerate other heavy metals from industrial effluents and sediments. Out of the six bacterial strains isolated from seleniferous sites of Punjab, three isolates (RS-1, RS-2, and RS-3) were screened out for further growth-associated lead sequestration and molecular characterization on the basis of their tolerance toward lead and other heavy metals. Biomass and cell-free supernatant were analyzed for lead contents using ICP-MS after growth-associated lead sequestration studies in tryptone soya broth (pH = 7.2 ± 0.2) under aerobic conditions at 37 °C temperature. Almost 82 % and 70 % divalent lead was sequestered in cell pellets of RS-1 and RS-3, respectively while only 45 % of lead was found in cell pellet of RS-2 in the first 24 h. However, significant biosequestration of lead was observed in RS-2 after 48 h of incubation with concomitant increase in biomass. Simultaneously, morphological, biochemical, and physiological characterization of selected strains was carried out. 16S rRNA gene sequence of these isolates revealed their phylogenetic relationship with class Bacillaceae, a low G + C firmicutes showing 98 % homology with Bacillus sp.

Is limitation of hip abduction a useful clinical sign in the diagnosis of developmental dysplasia of the hip?

AIM

The relationship between the presence and severity of sonographically diagnosed developmental dysplasia of the hip (DDH) and the clinical abnormality of limitation of hip abduction (LHA) was investigated.

METHODS

A prospective, longitudinal, selective 'at risk' and neonatal instability hip ultrasound programme between 1 January 1996 and 31 December 2005. 2876 neonates/infants were initially screened for DDH by clinical examination and by hip ultrasound imaging. Pathological sonographically evaluated DDH was considered to be Graf Type III, IV and irreducible hip dislocation. Inclusion criteria were cases of unilateral or bilateral limitation of hip abduction hip.

EXCLUSION CRITERIA

syndromal, neuromuscular and skeletal dysplasia cases.

RESULTS

492 children presented with LHA (55 unilateral LHA). The mean age of neonates/infants with either unilateral or bilateral LHA was significantly higher than those without (p<0.001). In the sonographic diagnosis of Graf Type III and IV dysplasias, unilateral LHA had a PPV of 40% compared with only 0.3% for bilateral LHA. The sensitivity of unilateral LHA increased to 78.3% and a PPV 54.7% after the age of 8 weeks for Graf Types III, IV and irreducible hip dislocation.

CONCLUSIONS

This study identifies a time-dependent association with unilateral LHA in the diagnosis of 'pathological' DDH after the age of 8 weeks. The presence of bilateral LHA in the young infant may be a normal variant and is an inaccurate clinical sign in the diagnosis of pathological DDH. LHA should be actively sought after 8 weeks of age and if present should be followed by a formal ultrasound or radiographic examination to confirm whether or not the hip is developing in a satisfactory manner.

Frontal sinus mucopyelocele with intracranial and intraorbital extension

This case is related to a 52-year-old lady with proptosis, diplopia and diminution of vision due to a mass lesion in upper medial quadrant of the orbit. CT scan revealed a well defined mass in basi-frontal area with intra-orbital and intracranial extension. On exploring it was found to be mucopyocele of the frontal sinus. Surgical excision was done by external approach. The symptoms and signs resolved completely within a week. Frontal sinus mucopyoceles are benign and curable. Early recognition and management of them is of paramount importance because they can expand and cause local, orbital or intracranial complications.

Effectiveness of etoposide chemomobilization in lymphoma patients undergoing auto-SCT

The effectiveness of stem cell mobilization with G-CSF in lymphoma patients is suboptimal. We reviewed our institutional experience using chemomobilization with etoposide (VP-16; 375 mg/m(2) on days +1 and +2) and G-CSF (5 μg/kg twice daily from day +3 through the final day of collection) in 159 patients with lymphoma. This approach resulted in successful mobilization (>2 × 10(6) CD34+ cells collected) in 94% of patients (83% within 4 apheresis sessions). Fifty-seven percent of patients yielded at least 5 × 10(6) cells in 2 days and were defined as good mobilizers. The regimen was safe with a low rate of rehospitalization. Average costs were $14 923 for good mobilizers and $27 044 for poor mobilizers (P<0.05). Using our data, we performed a 'break-even' analysis that demonstrated that adding two doses of Plerixafor to predicted poor mobilizers at the time of first CD34+ cell count would achieve cost neutrality if the frequency of good mobilizers were to increase by 21%, while the frequency of good mobilizers would need to increase by 25% if three doses of Plerixafor were used. We conclude that chemomobilization with etoposide and G-CSF in patients with lymphoma is effective, with future opportunities for cost-neutral improvement using novel agents.

Gastrointestinal Stromal Tumour of Meckel's Diverticulum Causing Perforation and Peritonitis: A Case Report

A 23-year-old man presented with history of fever and pain in the right lower abdomen. He was diagnosed to have acute appendicitis with perforation and was taken up for emergency laparotomy after resuscitation. There was pus in the right iliac fossa and a tumor at the fundus of Meckel's diverticulum, which had perforated. Appendix was found to be normal. The histopathology examination showed it to be gastrointestinal stromal tumor of Meckel's diverticulum. The gastrointestinal stromal tumor causing Meckel's diverticulum perforation and peritonitis is very rare, and prior to this indexed case, only two such cases have been reported in the literature.

Teratoma of the tongue

Teratomas are the benign tumours, which may occur anywhere in the body. Development of these lesions in the oral cavity is extremely rare. In the oral cavity, they usually arise in the midline, in the floor of mouth. Infrequently, they may be seen in the tongue proper. We hereby, present a case of swelling tongue in 56 years female diagnosed as teratoma.

Bronchoscopic management of benign bronchial stenosis by electrocautery and balloon dilatation

Benign bronchial stenosis is managed by surgical or bronchoscopic methods. Although surgical approach is definitive, it is technically demanding and is costlier than bronchoscopic treatment. Here, we report the case of a 27-year-old female patient with symptomatic benign bronchial stenosis of the left main bronchus. The stenosis was dilated successfully through a fibreoptic bronchoscope by electrocautery followed by balloon bronchoplasty and application of mitomycin-C. On follow up, there was no evidence of re-stenosis.

Endotracheal Tube Cuff Pressure Monitoring in Peripheral Hospitals

BACKGROUND

An improvised monitor was designed in a peripheral hospital to measure the tracheal tube cuff pressures in patients intubated under anaesthesia. The aim of the study was to assess the efficacy of assessment of cuff pressure by the traditional palpatory method and to compare the improvised monitor with the standard monitor commercially available. The effect of nitrous oxide on the cuff-pressure was also studied.

METHODS

The tracheal tube cuff pressure of 80 patients undergoing general anaesthesia was assessed by palpation and measured with an improvised and standard monitor.

RESULTS

The study showed that the tracheal cuff pressure recorded were higher than normal tracheal perfusion pressure in 40% of the cases with satisfactory palpatory assessment. The pressures recorded by the improvised monitor were comparable to that of the standard monitor. The use of nitrous oxide resulted in increase in cuff pressures over a period of time.

CONCLUSION

An objective measurement by any equipment is superior to assessment of cuff pressure by palpation. The improvised monitor can be used to give a fair idea of the cuff pressures, in places where a standard monitor is not available.