Kiloh-Nevin syndrome: an unusual cause of forearm pain

The popularity of weight training, bodybuilding and general physical conditioning has led to an increased rate of musculoskeletal injuries, such as nerve compression caused by muscle hypertrophy and, stretching of nerves peripherally. We present a case of anterior interosseous nerve (AIN) entrapment syndrome/neuropathy otherwise known as Kiloh-Nevin syndrome in a 22-year-old weightlifter. Knowledge of this injury is paramount for practitioners to increase awareness among athletes and bodybuilders.

Prognostic significance of soft tissue deposits in head and neck squamous cell carcinoma: a systematic review and meta-analysis

Soft tissue deposits, also known as tumour deposits (TDs), have not been studied well in head and neck squamous cell carcinoma (HNSCC) and are not included in any of the staging systems or treatment guidelines. The aim of this systematic review was to determine the prevalence and prognostic implications of TDs in patients with HNSCC. This systematic review of the literature was conducted following the PRISMA guidelines. The PubMed, Embase, and Scopus electronic databases were searched for relevant studies, from inception to August 2022. Although 14 studies qualified for inclusion, only eight were finally included in the review due to the considerable overlap of patients in several studies. Data from 7127 patients were analysed. The pooled prevalence of TDs was 21% (95% confidence interval (CI) 9-33%). The presence of TDs was adversely associated with overall survival and disease-free survival, with hazard ratios of 2.08 (95% CI 1.60-2.70) and 2.56 (95% CI 1.97-3.32), respectively. TDs are detected in a significant number of patients with HNSCC and adversely affect survival. Longitudinal prospective studies are needed to evaluate the prognostic implications of TDs in HNSCC for their potential role in cancer staging and adjuvant treatment planning.

Nociceptor Neurons Magnify Host Responses to Aggravate Periodontitis

Periodontitis is a highly prevalent chronic inflammatory disease that progressively destroys the structures supporting teeth, leading to tooth loss. Periodontal tissue is innervated by abundant pain-sensing primary afferents expressing neuropeptides and transient receptor potential vanilloid 1 (TRPV1). However, the roles of nociceptive nerves in periodontitis and bone destruction are controversial. The placement of ligature around the maxillary second molar or the oral inoculation of pathogenic bacteria induced alveolar bone destruction in mice. Chemical ablation of nociceptive neurons in the trigeminal ganglia achieved by intraganglionic injection of resiniferatoxin decreased bone loss in mouse models of experimental periodontitis. Consistently, ablation of nociceptive neurons decreased the number of osteoclasts in alveolar bone under periodontitis. The roles of nociceptors were also determined by the functional inhibition of TRPV1-expressing trigeminal afferents using an inhibitory designer receptor exclusively activated by designer drugs (DREADD) receptor. Noninvasive chemogenetic functional silencing of TRPV1-expressing trigeminal afferents not only decreased induction but also reduced the progression of bone loss in periodontitis. The infiltration of leukocytes and neutrophils to the periodontium increased at the site of ligature, which was accompanied by increased amount of proinflammatory cytokines, such as receptor activator of nuclear factor κΒ ligand, tumor necrosis factor, and interleukin 1β. The extents of increase in immune cell infiltration and cytokines were significantly lower in mice with nociceptor ablation. In contrast, the ablation of nociceptors did not alter the periodontal microbiome under the conditions of control and periodontitis. Altogether, these results indicate that TRPV1-expressing afferents increase bone destruction in periodontitis by promoting hyperactive host responses in the periodontium. We suggest that specific targeting of neuroimmune and neuroskeletal regulation can offer promising therapeutic targets for periodontitis supplementing conventional treatments.

Quality of life from cytoreductive surgery in advanced Ovarian cancer: investigating association with disease burden and surgical complexity in the international, prospective, SOCQER2 cohort study

OBJECTIVE

To investigate quality of life (QoL) and association with surgical complexity and disease burden after surgical resection for advanced ovarian cancer in centres with variation in surgical approach DESIGN: Prospective multicentre observational study SETTING: United Kingdom, Kolkata, India, and Melbourne, Australia gynaecological cancer surgery centres.

PARTICIPANTS

Patients undergoing surgical resection for late stage ovarian cancer. Exposure Low, intermediate or high Surgical Complexity Score (SCS) surgery MAIN OUTCOMES AND MEASURES: Primary: EORTC-QLQ-C30 Global score change. Secondary: EORTC OV28, progression free survival.

RESULTS

Patients' pre-operative disease burden and SCS varied between centres, confirming differences in surgical ethos. QoL response rates were 90% up to 18 months. Mean change from the pre-surgical baseline in the EORTC QLQ-C30 was 3.4 (SD 1.8, n=88) in the low, 4.0 (SD 2.1, n=55) in the intermediate and 4.3 (SD 2.1, n=52) in the high SCS group after 6 weeks (p=0.048) and 4.3 (SD 2.1, n=51), 5.1 (SD 2.2, n=41) and 5.1 (SD 2.2, n=35) respectively after 12 months (p=0.133). In a repeated measures model, there were no clinically or statistically meaningful differences in EORTC QLQ-C30 global scores between the three SCS groups, p= 0.840 but there was a small statistically significant improvement in all groups over time (p<0.001). The high SCS group experienced small to moderate decreases in physical (p=0.004), role (p=0.016) and emotional (p=0.001) function at 6 weeks post-surgery which resolved by 6-12 months.

CONCLUSIONS AND RELEVANCE

Global QoL of patients undergoing low, intermediate, and high SCS surgery improved at 12 months post operation and was no worse in patients undergoing extensive surgery.

Response evaluation of locoregional therapies in combined hepatocellular-cholangiocarcinoma and intrahepatic cholangiocarcinoma versus hepatocellular carcinoma: a propensity score matched study

AIM

To evaluate the response of locoregional therapy (LRT) on combined hepatocellular-cholangiocarcinoma (cHCC-CC) and intrahepatic cholangiocarcinoma (IHC) and compare their outcomes with propensity matched hepatocellular carcinoma (HCC) patients.

MATERIALS AND METHODS

From January 2011 to July 2020, 13 patients with cHCC-CC (11 men, two women, median age 56 years) and 15 IHC patients (10 men, five women, median age 60 years) were compared with 101 HCC patients (79 men, 22 women, median age 60 years) after LRT. All tumours were proven histologically. Among the 13 cHCC-CC patients, 11 received transarterial chemoembolisation (TACE), one received microwave ablation (MWA) and one received TACE with radiofrequency ablation (RFA). Of 15 IHC patients, eight received TACE, five received RFA, and one received MWA, and one received TACE with RFA. Propensity score matching (PSM) was done with conditional logistic regression adjusted for age, type of LRT, tumour specific features and Child-Pugh score.

RESULTS

After LRT, on univariate analysis an objective response was seen in 30% of cHCC-CC and 53% of IHC patients. PSM analysis demonstrated shorter progression-free survival (PFS; cHCC-CC versus HCC: 1.5 versus 7.5 months; IHC versus HCC: 6 versus 14 months, p<0.05), overall survival (OS; cHCC-CC versus HCC: 12 versus 28 months; IHC versus HCC: 18 versus 34 months, p<0.005), and poor objective response (cHCC-CC versus HCC: 25% versus 91%; IHC versus HCC: 58% versus 88%, p<0.05) in cHCC-CC and IHC patients versus HCC patients. Hypovascular tumour, macrovascular invasion, and infiltrative appearance were independent prognostic factors for OS in IHC patients.

CONCLUSION

cHCC-CC and IHC are aggressive tumours with a poor objective response, greater distant progression of the disease and shorter PFS and OS post LRT as compared to HCC.

Impact of coronavirus disease 2019 on ENT clinical practice and training: the resident's perspective

BACKGROUND

The arrival of the coronavirus disease 2019 pandemic disrupted life suddenly and forcefully, and healthcare systems around the world are still struggling to come to terms with it. This paper reviews the impact of the pandemic on ENT practice and training.

METHODS

The present manuscript was developed as a narrative review to examine the role of otorhinolaryngologists in the management of the pandemic, and assess its impact on practice and training in the specialty.

RESULTS

Otorhinolaryngologists handle secretions of organs implicated in disease transmission, leaving them particularly vulnerable even while performing simple procedures. Although the pandemic increased skill expectations, it simultaneously reduced learning opportunities for trainees. In addition, attention to emergencies has been delayed. Further, the suspension of elective procedures has affected patients with malignancies.

CONCLUSION

While planning service resumption, provisions need to be made for protective equipment and training; improving teleconsultation services will help provide sustainable care during further waves.

Optimizing antibiotic use for early onset sepsis: A tertiary NICU experience

BACKGROUND

Neonatal antibiotic use is associated with a greater risk of nosocomial infection, necrotizing enterocolitis, and mortality. It can induce drug-resistant pathogens that contribute to increased neonatal morbidity/mortality, healthcare costs, and length of stay. Prior to the antibiotic stewardship program, decisions to obtain blood cultures and empiric antibiotics for possible Early-onset Sepsis (EOS) in late preterm and term infants upon NICU admission were provider-dependent rather than algorithm-based. We aimed to decrease empiric antibiotic prescription from 70% to 56% (20% decrease) in infants ≥34 weeks gestation admitted to the NICU.

METHODS

The stewardship initiative comprised the following practice changes: (1) use of the Neonatal Sepsis Risk Calculator (SRC); and (2) a 36-hour time-out for prescribed empiric antibiotics. Data was retrospectively collected and analyzed for inborn infants pre-intervention (January 2015-December 2015; n = 263) and post-intervention (August 2016-September 2017; n = 279). Data regarding compliance with the new antibiotic guideline were collected and disseminated to the team every week. Overlap between CDC guidelines and calculator recommendations were studied.

RESULTS

Pre-and post-intervention outcomes were analyzed using chi-square tests. There was a significant post-intervention reduction in the rate of both antibiotic prescriptions (29.4% decline; 70.3% vs. 49.6%; p < 0.001) and sepsis evaluations (24.3% decline; 90.9% vs. 68.8%; p < 0.001). No difference (p = 0.271) in culture-positive EOS cases was observed. There was 92% overlap in blood culture recommendations and 95% overlap between antibiotic recommendations when current CDC guidelines were compared to the SRC.

CONCLUSION

A significant reduction in antibiotic use and sepsis evaluations was achieved for late preterm and term infants upon NICU admission. No clinical deterioration occurred in post-intervention infants who did not receive antibiotics. There is significant overlap between CDC guidelines and SRC recommendations.

Practical consensus recommendatons for Paget's disease in breast cancer

Paget's disease of the breast is a rare type of cancer of the nipple-areola complex and that is often associated with an underlying in situ or invasive carcinoma. Diagnosis and treatment of Paget's disease is controversial. Expert oncologists discuss on the update on the approaches of Paget's disease diagnosis and its treatment options. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Retrospective Analysis of Giant Cell Tumor Lower End Radius Treated with En bloc Excision and Translocation of Ulna

BACKGROUND

Distal end of radius is third most common site for GCT of long bones and 1% of these metastasize mostly to lungs. Reconstruction methods commonly used are fibula (vascularized and nonvascularized), centralization of ulna, translocation of ulna, and endoprosthetic replacement. We report the outcome of series of twenty cases where we did en bloc excision of tumor with translocation of ulna.

MATERIALS AND METHODS

Twenty cases of giant cell tumor (GCT) of lower end of radius were included in this retrospective study. The mean age of patients was 33.15 years (range 21-55 years). We had 14 of Campanacci Grade III and 6 of Grade II. Preoperative radiographs and magnetic resonance imaging of the involved wrist and forearm were done.

RESULTS

Of all twenty patients, 14 were males and 6 were females. Mean followup duration was 3.9 years (range 1.5-17 years). Mean grip strength of involved side as a percentage of normal side was 71% (range 42%-86%) and the actual mean value for operated side was 29 kg as compared to 40 kg for normal side. The average range of forearm movement was supination 80.25° (60°-90°) and pronation 77.5° (70°-90°). No patient was dissatisfied as far as cosmesis was concerned.

DISCUSSION

In our opinion considering the propensity to recur with more aggressiveness after recurrence, en bloc excision with translocation of ulna has become a standard treatment option for GCT of lower end of radius, with advantages of better functional outcomes, retained vascularity, and elimination of risk of donor site morbidity.

Clinical presentation, management, and outcomes in the Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF) registry

Aim

A national atrial fibrillation (AF) registry was conducted under the aegis of the Indian Heart Rhythm Society (IHRS), to capture epidemiological data-type of AF, clinical presentation and comorbidities, current treatment practices, and 1-year follow-up outcomes.

Methods

A total of 1537 patients were enrolled from 24 sites in India in the IHRS-AF registry from July 2011 to August 2012. Their baseline characteristics and follow-up data were recorded in case report forms and subsequently analyzed.

Results

The average age of Indian AF patients was 54.7 years. There was a marginal female preponderance – 51.5% females and 48.5% males. At baseline, 20.4% had paroxysmal AF; 33% had persistent AF; 35.1% had permanent AF and 11% had first AF episode. At one-year follow-up, 45.6% patients had permanent AF.

Rheumatic valvular heart disease (RHD) was present in 47.6% of patients. Hypertension, heart failure, coronary artery disease, and diabetes were seen in 31.4%, 18.7%, 16.2%, and 16.1%, respectively.

Rate control was the strategy used in 75.2% patients, digoxin and beta-blockers being the most frequently prescribed rate-control drugs. Oral anticoagulation (OAC) drugs were used in 70% of patients. The annual mortality was 6.5%, hospitalization 8%, and incidence of stroke 1%.

Conclusions

In India, AF patients are younger and RHD is still the most frequent etiology. Almost two-third of the patients have persistent/permanent AF. At one-year follow-up, there is a significant mortality and morbidity in AF patients in India.

Implant-retained auricular prostheses: a clinical challenge

Microtia, malformation, deformity, and partial or complete loss of the pinna may be due to various congenital or acquired factors. In adult patients, surgical reconstruction of the missing pinna is difficult and the results are often far from satisfactory. An implant-retained auricular prosthesis is a suitable alternative. A retrospective study of eight patients treated with implant-retained auricular prostheses was performed. For each missing pinna, three titanium implants were placed in the temporal bone. After 6 months of osseointegration, the implants were loaded. Four cases were rehabilitated with a magnet-retained prosthesis and the remaining four with a bar and clip retained prosthesis. There were six male and two female patients with an average age of 30.62 years. Seven patients had unilateral absence of the pinna and one had bilateral absence. The loss was due to trauma in four patients and to burn in one patient, and three had congenital absence. A total 27 implants were placed, 12 on the right side and 15 on the left. The average post-rehabilitation follow-up was 21 months. Peri-implant tissue reactions were observed at two sites. The implant-retained auricular prosthesis is an alternative treatment approach with good retention and patient satisfaction. Long-term follow-up is required to assess delayed complications.

Endophthalmitis caused by Acinetobacter baumanni: a case series

PURPOSE

To profile the etiology, clinical outcomes and drug sensitivity patterns in endophthalmitis caused by Acinetobacter baumanni.

METHODS

Retrospective analysis of all the cases of Acinetobacter baumanni endophthalmitis presenting to tertiary referral care ophthalmic hospital in Eastern India from January 2009 to December 2011 were done.

RESULTS

A total of four cases were included in the study. Out of the four cases one was post traumatic and the rest were post cataract surgery. All the cases underwent vitreoretinal surgical intervention followed by intravitreal antibiotics. A. Baumanni was isolated from vitreous in all the cases. Among all the drugs tested bacteria were found sensitive to ciprofloxacin (100 %) whereas all tested resistant to ceftazidime. Out of the four cases one had to be eviscerated, another developed retinal detachment post vitrectomy, one was phthisical at final followup, and only one patient achieved a vision of 20/200 with clear media and attached retina at final visit.

CONCLUSION

A. Baumanni is a very rare cause of endophthalmitis with poor visual and anatomical outcomes. Ciprofloxacin should be considered as first the line intravitreal antibiotic.

Cytokine imbalance in systemic lupus erythematosus: a study on northern Indian subjects

OBJECTIVE

The phenotype of systemic lupus erythematosus (SLE) in Asian Indians is more severe as compared with that in Caucasians. The reason is not clear. In this context, we studied serum levels of interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), interleukin-4 (IL-4) and interlekin-10 (IL-10). Their interrelations and correlation with SLEDAI scores were evaluated.

MATERIALS AND METHODS

Forty patients with active SLE and 40 controls were studied. The mean SLEDAI score and anti-ds DNA level of the patients were 21.45 ± 8.61 and 176.68 ± 81.31 (IU/ml), respectively. Cytokines were estimated by enzyme-linked immunosorbent assay.

RESULTS

In controls, the levels of IFN-γ were highest, followed by TNF-α, IL-10 & IL-4. In patients, however, the levels of TNF-α were highest, followed by IFN-γ, IL-10 & IL-4. IL-10 and IL-4 correlated negatively, and IFN-γ and TNF-α correlated positively with the SLEDAI scores. As compared with controls, in patients, the mean values of TNF-α, IL-10 and TNF-α/IL-10 ratio were higher by 6.9, 2.9 and 2.3 times, respectively (p < 0.001). Significant positive correlation was found between these two cytokines in patients (r = 0.327, p < 0.05) but not in controls. The levels and ratio of IL-4 and IFN-γ were comparable between patients and controls. These two cytokines correlated negatively both in controls (r = -0.358, p < 0.05) and patients (r = -0.990, p < 0.001). The ratio of TNF-α/IL-4 was 4.2 times higher, and those of IFN-γ/IL-4 and IFN-γ/IL-10 were 1.89 and 3.40 times lower in patients as compared with controls. A positive correlation between IL-10 and IL-4 (r = 0.345, p < 0.05) and a negative correlation between IL-10 and IFN-γ (r = -0.382, p < 0.05) were observed only in patients.

CONCLUSION

This study showed a distinct profile of cytokine imbalance in patients with SLE from the northern plains of India. The levels, ratios and correlations of cytokines in patients suggested significant deviation from normal. Correlations of cytokines with SLEDAI scores indicated that TNF-α contributes significantly to the pathological manifestations of SLE in patients from the region. A detailed study is warranted.

Curcumin ameliorates reserpine-induced pain-depression dyad: behavioural, biochemical, neurochemical and molecular evidences

An apparent clinical relationship between pain and depression has long been recognized. Depression and pain are often diagnosed in the same patients. The emerging concept for pain-depression pathogenesis is the dysfunction of biogenic amine-mediated pain-depression control and the possible involvement of nitrodative stress-induced neurogenic inflammation. The present study was designed to investigate the effect of curcumin on reserpine-induced pain-depression dyad in rats. Administration of reserpine (1mg/kg subcutaneous daily for three consecutive days) led to a significant decrease in nociceptive threshold as evident from reduced paw withdrawal threshold in Randall Sellitto and von-Frey hair test as well as significant increase in immobility time in forced swim test. This behavioural deficit was integrated with decrease in the biogenic amine (dopamine, norepinephrine and serotonin) levels along with increased substance P concentration, nitrodative stress, inflammatory cytokines, NF-κβ and caspase-3 levels in different brain regions (cortex and hippocampus) of the reserpinised rats. Curcumin (100, 200, 300mg/kg; ip) dose dependently ameliorated the behavioural deficits associated with pain and depression by restoring behavioural, biochemical, neurochemical and molecular alterations against reserpine-induced pain-depression dyad in rats.

High Horn's index score predicts poor outcomes in patients with Clostridium difficile infection

Several variables have been proposed to predict the prognosis of patients with Clostridium difficile infection (CDI), but a clinically useful tool to stratify resource utilization has not been determined. Horn's index, a severity score based on underlying clinical illness, reliably predicts patients at high risk of CDI. The purpose of this study was to assess the use of Horn's index to stratify patients with CDI at high risk of poor clinical and economic outcomes. Hospitalized patients diagnosed with CDI were followed prospectively for three months. Horn's index scores were calculated for each patient on the day of the positive toxin test for C. difficile, and used to stratify differences in outcome variables (length of hospital stay, mortality and hospital costs). Eighty-five CDI patients (50% male, 64% Caucasian) were recruited. Discharge mortality was 0% for patients with Horn's index scores of 1 or 2, 5% for those with a score of 3, and 50% for those with a score of 4 (P < 0.001). Three-month mortality was 0%, 5%, 17% and 60% for patients with Horn's index scores of 1, 2, 3 and 4, respectively (P = 0.0004). Median three-month hospital costs were $8,585, $12,670, $29,077 and $68,708 for patients with Horn's index scores of 1, 2, 3 and 4, respectively (P < 0.001). Patients with Horn's index scores of 3 or 4 had a significantly longer hospital stay [mean 33.4 (standard deviation, SD 33.3) days] than patients with scores of 1 or 2 [mean 15.1 (SD 16.2) days, P = 0.001]. This study found Horn's index to be a simple and useful method for identifying CDI patients at high risk of poor clinical and economic outcomes.

Relationship of leukocyte CR1 transcript and protein with the pathophysiology and prognosis of systemic lupus erythematosus: a follow-up study

Complement Receptor 1 (CR1) is a key complement regulatory protein (CRP) involved in the clearance of immune complexes. Earlier, we reported a marked decline of leukocyte CR1 (L-CR1) transcript and protein in patients with active systemic lupus erythematosus (SLE) and suggested L-CR1 transcript as a putative non-invasive disease marker for SLE. This follow-up study involving 18 patients with active SLE was conducted for further confirmation of the relationship between L-CR1 and SLE. Blood samples from the patients were collected on day 1 of the diagnosis (0 month) and at different time intervals (3 and 6 months) for analysis of L-CR1 transcript and L-CR1 protein by semi-quantitative reverse-transcriptase-polymerase chain reaction (RT-PCR) and western blotting respectively. Within 6 months, 15 patients entered remission. On day 1, the mean values of L-CR1 transcript (8.42 ± 3.53) and L-CR1 protein (4683 ± 1094) in the SLE patients were 6 times and 12 times lower than the normal controls (n = 103). At the end of month 6, these values increased by 4.5 and 6.5 times respectively for CR1 transcript (37.86 ± 8.52) and protein (30,265 ± 8614). Simultaneously, the SLE Disease Activity Index (SLEDAI) scores decreased by 4.8 times (4.47 ± 3.32) as compared with the scores obtained on day 1 (21.45 ± 5.67). Moreover, CR1 values correlated negatively with the SLEDAI scores. Levels of L-CR1 protein and transcript remained low in the three patients who did not enter remission. All of the above results suggested that an increase in the levels of L-CR1 related to good prognosis. Since the levels of L-CR1 protein is influenced by variables like proteolytic cleavage and secretion from leukocytes, the values of L-CR1 transcript on day 1 and subsequent follow-up points may bring a better insight into the state of the disease activity. An extended follow-up study is needed to confirm the significance of L-CR1 as a prognostic marker for SLE.

A Note on the Effect of Hamycin on Electrolytes in the Frog Heart

Treatment of frog heart with hamycin, an antifungal antibiotic, effected an increase in the potassium content of perfusion fluid. Changes in sodium content were not observed.

Radial nerve entrapement in osseous tunnel without clinical symptoms

Entrapment of a nerve in the callus of a healing fracture is not a common entity, but it does exist. The entrapment usually presents without neurological deficit. It is difficult to suspect the radial nerve injury if we need to operate on the same site. We present a case of entrapment of radial nerve in the callus of a supracondylar humerus fracture with cubitus varus deformity. The surgery for correction of the deformity led to the damage of the nerve. In retrospect a careful assessment of the x-rays showed two 3-4 mm diameter holes. Awareness of this finding would have given us sufficient indication of nerve entrapment to prevent this mishap.