Flap Design for Cranial Reconstruction: An Analysis of Craniectomy and Cranioplasty Incisions

Background

The surgical approach for cranial reconstruction is influenced by the presence of pre-existing scar tissue. Scars that lie within the vicinity of cranial defect require modification.

Purpose

The present study was conducted to analyse co-relation between craniectomy scar and cranioplasty incision.

Materials and Methods

A retrospective evaluation of 70 patients who were divided into three groups based on location of cranioplasty incision line was done. In group I, incision was located parallel and outside the scar; group II, incision was located over the scar; and group III, mixed and criss-cross incision was present. The primary outcome variable of interest was to analyse co-relation between craniectomy and cranioplasty incisions.

Results

There were 45 cases of group I, 15 cases of group II and 10 cases of group III. Thirty-three patients had defect on left side, 26 had on right side, and 10 had bifrontal defect. No significant association was noted between the site and cranioplasty incision (Chi2 = 9.155, p = 0.433 and likelihood ratio = 9.487, p = 0.394).

Conclusion

Well-vascularized broad-based scalp flap that provides adequate exposure and located on healthy bone irrespective of pre-existing craniectomy scar forms the mainstay of successful cranial reconstruction.

Incidence of Facial Nerve Injury and Sialocele Formation Following Mandibular Condylar and Sub-condylar Fracture Fixation

Purpose

To study the incidence of sialocele formation in the parotid gland and to study the incidence of facial nerve affliction following treatment of mandibular condylar and sub-condylar fractures.

Materials and methods

The present study is a retrospective study conducted on a total of 82 patients with 107 sub-condylar and condylar fractures treated in this centre from August 2008 to August 2020. The surgical approaches used to treat the fractures were considered, and the occurrence of sialocele, salivary fistula and facial nerve paralysis was noted. The facial nerve function was analysed using House-Brackmann system of classification.

Results

The incidence of sialocele formation was seen in 15.87% of cases, and the incidence was seen more commonly during a preauricular approach (52.94%) followed by retromandibular (41.17%) followed by anterior parotid transmassetric approach (11.76%). The incidence of facial nerve affliction was seen in 17.57% of cases with majority of them showing temporal branch involvement in 21.05% of cases.

Conclusion

During the treatment of condylar and sub-condylar fractures, the facial nerve is at considerable risk of damage; however, understanding the anatomy of the nerve is of importance to avoid such complications. Sialocele formation is also an undesirable complication of such surgeries, a prompt diagnosis and early treatment is mandatory to overcome further unwanted sequel.

Interim management of Pierre Robin sequence using a custom-made face mask

Pierre Robin sequence poses a great challenge for anesthesiologists during laryngoscopy and intubation, making oxygenation and ventilation difficult. The role of early surgical intervention is recommended for the improvement of the airway and overall survival of the neonate. The situation becomes even more challenging, when the neonate may not be fit for such surgical interventions. The present case posed such a challenge to the team. To the authors' knowledge, the decision to use a face mask as an interim life-saving measure was considered for the first time. This provided a greater window of opportunity for further course of action, only to be later managed by distraction osteogenesis of the mandible. The unconventional use of orthopedic appliances for the management of threatened airways may provide the clinician with time, where further management may be carried out. The present article will explain such a procedure that was carried out as a life-saving measure.

Role of concomitant percutaneous pie crusting and local corticosteroid injection in lateral epicondylitis: a prospective, case control study

BACKGROUND

Lateral epicondylitis is an increasingly debilitating condition in working population. Evidence for conservative treatment modalities has been inconclusive. Percutaneous pie crusting of the common extensor origin at the lateral epicondyle at the time of local corticosteroid injection (CSI) has been proposed sparsely. The objective of this study was to analyze if concomitant CSI and pie-crusting of the common extensor origin provides better outcome than CSI alone in lateral epicondylitis.

METHODS

This case-control study on 236 patients was conducted at a single center between January 1, 2020, and May 31, 2022. Patients were divided into two groups (n=118 each) based on their preference. Group A underwent CSI alone and group B underwent pie crusting along with CSI. The clinical and functional outcomes of all patients were evaluated at 2, 4, 6, and 12-week post-procedure using the visual analog scale (VAS) and Nirschl score. The mean time for return to daily activities was also compared.

RESULTS

Both groups showed significant improvement in post-procedure outcome at successive follow-ups on intragroup longitudinal analysis (VAS: F=558.384 vs. F=1,529.618, Nirschl: F=791.468 vs. F=1,284.951). On intergroup analysis, VAS of group B was superior to that of group A; however, it was statistically significant (P<0.05) only from the 6-week follow-up onwards. Nirschl score of group B was significantly better throughout the period of follow-up (P<0.05). Group B returned to daily activities faster than Group A (6.2±0.44 weeks vs. 7.18±0.76 weeks).

CONCLUSIONS

Concomitant pie crusting with CSI is recommended for lateral epicondylitis as it provides significantly better results than CSI alone.

Krabbe's disease; A rare case report

Krabbe's disease (globoid cell leukodystrophy) is a rare lysosomal storage disorder in which galactocerebroside and psychosine accumulate in macrophages and demyelination of white matter of the cerebrum. We present a case of Krabbe's disease with enlargement of optic nerves in gross autopsy findings, presence of globoid cells in histology and MR images showing abnormal signals.

Evaluation of occlusal forces using T scan analysis following mandibular fracture fixation

Introduction

Mandible receives maximum impact following maxillofacial trauma. The dentate segment in particular is of importance as it has a direct bearing on the occlusive forces. The studies that have been carried out are either based on crude clinical evaluations or make use of elaborate and labor-intensive techniques. This study made use of T-scan analysis for objective identification of occlusive forces following mandibular fracture fixation.

Materials and Methods

Eighty clinic-radiologically diagnosed cases of dentate segments of the mandible were considered, after random sampling method. The occlusion analysis was done by use of a T scan to obtain Relatively Occlusal Force. The procedure was repeated at 04-, 24-, 36-, and 48-weeks intervals. The data was recorded on Excel Spreadsheet (Microsoft Inc) and analysis was done using SPSS software.

Results

The cases were predominantly males with a homogenous distribution of cases of age. The age versus gender distribution was more skewed in the female subgroup with a higher kurtosis value. Both evaluative (Pearson's) and inferential (paired t) tests were applied to reason the study. It was observed that the ROF values decreased in values as compared to pre-operative/post-treatment (Difference of Mean = 2.19, SE = 2.13) compared to 4 (Difference of Mean = -0.40 SE = 0.188),24 (Difference of Mean = -1.22, SE = 0.24) and 36 (Difference of Mean = -3.24, SE = 0.30) weeks, which however surpassed the pre-operative levels at 48 weeks post-operative period. This is suggestive of impending muscular imbalance in the initial periods. The surpass of 48 weeks may be due to optimal forces that were their pre-trauma.

Conclusion

Mandibular fracture fixation is the most widely used and also a time-tested modality in the management of mandibular trauma. The evaluation of occlusive forces needs an understanding of their behavior following such fixation. The present study used T-scan analysis to objectify such forces and added extra insight apart from clinical evaluations of tooth contact and parafunctional movements.

Mucormycosis coinfection post-COVID-19 recovery: Early suspicion and prompt action

Severe acute respiratory syndrome coronavirus 2 infection has resulted in a pandemic, the disease manifests itself as various conditions ranging from respiratory disorders to exacerbated inflammatory responses. The management in some cases involves immediate care in an intensive setup with the administration of various antibiotics and steroids which has resulted in the imposition of risk factors and growth of fulminant fungal infection. The present article addresses two such cases which presented with osteomyelitis secondary to mucormycosis in patients who had more than one episode of COVID-19 infection. The upsurge of existing manifestation and development of opportunistic infections has to be considered in patients who are suffering or recovering from COVID-19. The COVID-19 scenario brings up a possibility of many bacterial and fungal infections in its aftermath. This article brings out two such opportunistic aggressive fungal infections and comprehensive management of the same.

Concomitant pulmonary disease is common among patients with extrapulmonary TB

BACKGROUND :

Microbiologic screening of extrapulmonary TB (EPTB) patients could inform recommendations for aerosol precautions and close contact prophylaxis. However, this is currently not routinely recommended in India. Therefore, we estimated the proportion of Indian patients with EPTB with microbiologic evidence of pulmonary TB (PTB).

METHODS :

We characterized baseline clinical, radiological and sputum microbiologic data of 885 adult and pediatric TB patients in Chennai and Pune, India, between March 2014 and November 2018.

RESULTS :

Of 277 patients with EPTB, enhanced screening led to the identification of 124 (45%) with concomitant PTB, including 53 (19%) who reported a cough >2 weeks; 158 (63%) had an abnormal CXR and 51 (19%) had a positive sputum for TB. Of 70 participants with a normal CXR and without any cough, 14 (20%) had a positive sputum for TB. Overall, the incremental yield of enhanced screening of patients with EPTB to identify concomitant PTB disease was 14% (95% CI 12–16).

CONCLUSIONS :

A high proportion of patients classified as EPTB in India have concomitant PTB. Our results support the need for improved symptom and CXR screening, and recommends routine sputum TB microbiology screening of all Indian patients with EPTB.

Measuring TB drug levels in the hair in adults and children to monitor drug exposure and outcomes

INTRODUCTION: Testing for anti-TB drugs in small hair samples may serve as a non-invasive tool to measure cumulative drug exposure and/or adherence, as these determine treatment success. We aimed to assess how well hair assays of TB drugs predict TB treatment outcomes.METHODS: A small thatch of hair, ~30 strands, was cut from the occipital region in adults and children from a prospective TB cohort in India. Isoniazid (INH), acetyl-INH and pyrazinamide (PZA) were extracted from the hair samples and quantified using liquid-chromatography-tandem mass spectrometry. The relationship between drug concentrations in hair and time to unfavourable outcomes was assessed using Cox-proportional hazards regression models.RESULTS: A two-fold increase in hair acetyl-INH concentrations in the 264 participants in our cohort with hair assays for TB drugs indicated a lower hazard of unfavourable TB treatment outcomes (aHR 0.67, 95%CI 0.44-1.02) and TB treatment failure (aHR 0.65, 95%CI 0.42-1.01). Higher summed concentrations (a summed measure of INH and acetyl-INH) indicated a lower hazard of treatment failure (aHR 0.69, 95%CI 0.45-1.05)CONCLUSION: Hair levels of INH and its metabolite may predict TB treatment outcomes, indicating the potential utility of this measure to assess and optimise TB treatment outcomes.

Unhealthy alcohol use independently associated with unfavorable TB treatment outcomes among Indian men

BACKGROUND: Approximately 10% of incident TB cases worldwide are attributable to alcohol. However, evidence associating alcohol with unfavorable TB treatment outcomes is weak.METHODS: We prospectively evaluated men (≥18 years) with pulmonary TB in India for up to 24 months to investigate the association between alcohol use and treatment outcomes. Unhealthy alcohol use was defined as a score of ≥4 on the Alcohol Use Disorders Identification Test-Concise (AUDIT-C) scale at entry. Unfavorable TB treatment outcomes included failure, recurrence, and all-cause mortality, analyzed as composite and independent endpoints.RESULTS: Among 751 men, we identified unhealthy alcohol use in 302 (40%). Median age was 39 years (IQR 28-50); 415 (55%) were underweight (defined as a body mass index [BMI] <18.5 kg/m²); and 198 (26%) experienced an unfavorable outcome. Unhealthy alcohol use was an independent risk factor for the composite unfavorable outcome (adjusted incidence rate ratio [aIRR] 1.47, 95% CI 1.05-2.06; P = 0.03) and death (aIRR 1.90, 95% CI 1.08-3.34; P = 0.03), specifically. We found significant interaction between AUDIT-C and BMI; underweight men with unhealthy alcohol use had increased risk of unfavorable outcomes (aIRR 2.22, 95% CI 1.44-3.44; P < 0.001) compared to men with BMI ≥18.5 kg/m² and AUDIT-C <4.CONCLUSION: Unhealthy alcohol use was independently associated with unfavorable TB treatment outcomes, highlighting the need for integrating effective alcohol interventions into TB care.

Prevalence and predictors of bacterial vaginosis in HIV-infected women in Maharashtra, India

We evaluated the prevalence and determinants of bacterial vaginosis (BV) in HIV-infected women from Maharashtra, India. Among 912 HIV-infected women enrolled, BV was diagnosed in 191 (20.9%) and intermediate BV was diagnosed in 258 (28.3%) women. Women with more than two pregnancies had 1.6 times increased risk of BV (95% CI 1.0, 2.5, p-value 0.038), women who were menopausal had 6.2 times increased risk of BV (95% CI 2.4, 15.6, p-value <0.001) and women who were human papillomavirus (HPV) positive had 2.3 times increased risk of BV (95% CI 1.4, 3.9, p-value 0.001). Although we observed significantly increased risk of BV among women diagnosed with cervical intraepithelial neoplasia or worse disease in the univariate analysis (odds ratio 3.5, 95% CI 1.5, 8.1, p-value 0.004), it did not reach statistical significance in the multivariate analysis. Women who had the first sexual intercourse after the age of 18 had significantly lower risk of BV. To conclude, we observed high prevalence of BV in HIV-infected women and increased risk of BV in HPV positive, HIV-infected women.

Analysis of Relapsed/Refractory Hodgkin Lymphoma Treated with Autologous Transplantation: A Single-Center Experience

Introduction: Hodgkin lymphoma (HL) is one of the common lymphomas with high cure rate. Aims: The aim was to study the outcome of relapsed/refractory HL treated with autologous transplantation. Objectives: The objective was to study the overall survival, overall response, and disease-free survival of the relapsed/refractory HL after autologous transplantation. Methods: It was a retrospective study conducted over a period of 8 years in our center using computer-based database and medical records as the data source. Results: A total of 22 patients were diagnosed with relapsed/refractory HL of which majority of cases were male patients (59%) with a mean age of 29 years (range: 15–57 years) and were Stage 4A (40.9%), with nodular sclerosis (54.5%). The overall response rate was 81.8% with 9.1% complete response, 72.7% partial response, and 4.5% stable disease; the overall survival was 77.92 ± 6.65 months, and disease-free survival was 69.66 ± 8.13 months. Conclusion: Autologous stem cell transplant plays an integral role in the treatment of patients with relapsed/refractory Hodgkin lymphoma.

Trends in HbA1c levels and implications for diabetes screening in tuberculosis cases undergoing treatment in India

SETTING

The optimal timing of screening for diabetes mellitus (DM) among tuberculosis (TB) cases is unclear due to the possibility of stress hyperglycemia.

DESIGN

We evaluated adult (18 years) pulmonary TB cases at treatment initiation as well as at 3 months, 6 months and 12 months. DM was identified by self-report (known DM) or glycated hemoglobin (HbA1c)  6.5% (new DM). Trends in HbA1c levels during treatment were assessed using non-parametric tests.

RESULTS

Of the 392 participants enrolled, 75 (19%) had DM, 30 (40%) of whom had new DM. Of the 45 participants with known DM, respectively 37 (82%) and 40 (89%) received medication to lower glucose levels at treatment initiation and completion; one participant with new DM initiated glucose-lowering medication during follow-up. The median HbA1c level in participants with known, new and no DM was respectively 10.1% (interquartile range [IQR] 8.3-11.6), 8.5% (IQR 6.7-11.5) and 5.6% (IQR 5.3-5.9) at treatment initiation, and 8.7% (IQR 6.8-11.3), 7.1% (IQR 5.8-9.5) and 5.3% (IQR 5.1-5.6) at treatment completion (P < 0.001). Overall, 5 (12%) with known and 13 (43%) with new DM at treatment initiation had reverted to HbA1c < 6.5% by treatment completion (P = 0.003); the majority of reversions occurred during the first 3 months, with no significant reversions beyond 6 months.

CONCLUSION

HbA1c levels declined with anti-tuberculosis treatment. Repeat HbA1c testing at treatment completion could reduce the risk of misdiagnosis of DM.

Diabetes and pre-diabetes among household contacts of tuberculosis patients in India: is it time to screen them all?

SETTING

Pre-diabetes mellitus (pre-DM) and DM increase the risk of developing tuberculosis (TB). Screening contacts of TB patients for pre-DM/DM and linking them to care may mitigate the risk of developing TB and improve DM management.

OBJECTIVE

To measure the prevalence of pre-DM/DM and associated factors among the adult household contacts (HHCs) of pulmonary TB patients.

METHODS

Between August 2014 and May 2017, adult HHCs of newly diagnosed adult PTB patients in Pune and Chennai, India, had single blood samples tested for glycosylated haemoglobin (HbA1c) at enrolment. DM was defined as previously diagnosed, self-reported DM or HbA1c 6.5%, and pre-DM as HbA1c between 5.7% and 6.4%. Latent tuberculous infection (LTBI) was defined as a positive tuberculin skin test (5 mm induration) or QuantiFERON® Gold In-Tube (0.35 international units/ml).

RESULTS

Of 652 adult HHCs, 175 (27%) had pre-DM and 64 (10%) had DM. Forty (64%) HHCs were newly diagnosed with DM and 48 (75%) had poor glycaemic control (HbA1c 7.0%). Sixty-eight (22%) pre-DM cases were aged 18-34 years. Age 35 years, body mass index 25 kg/m2, chronic disease and current tobacco smoking were significantly associated with DM among HHCs.

CONCLUSIONS

Adult HHCs of TB patients in India have a high prevalence of undiagnosed DM, pre-DM and LTBI, putting them at high risk for developing TB. Routine DM screening should be considered among all adult HHCs of TB.

Acute Pancreatitis Caused by Pemetrexed, Carboplatin, and Gemcitabine in a Patient with Lung Cancer: A Rare Case Report

Drug-induced pancreatitis is reported as one of the less common causes of acute pancreatitis. Many drugs such as sulfonamides, estrogens, tetracyclines, valproic acid, antiretroviral drugs, some chemotherapy drugs such as azathioprine, and 6 MP are known to cause acute pancreatitis. We report a case of acute pancreatitis following administration of chemotherapy for non-small cell lung cancer (NSCLC). The patient was diagnosed to have NSCLC (histologically proven adenocarcinoma). After thorough evaluation including radiological investigations consisting of a positron-emission tomography computed tomography scan, he was staged as a Stage III B NSCLC. As per protocol, he was started on combination chemotherapy with pemetrexed and carboplatin. After 2 weeks of chemotherapy, he developed acute pancreatitis which was managed conservatively. He was administered different drug combination during the next cycle involving gemcitabine and carboplatin. However, he developed recurrent acute pancreatitis which was managed conservatively. He was then referred to the radiotherapy department as it was deemed that he is at risk of recurrent episodes of pancreatitis if further cycles of chemotherapy are continued.

Prevalence of dysglycemia and clinical presentation of pulmonary tuberculosis in Western India

SETTING

Pune, India.

OBJECTIVES

To estimate the prevalence and risk factors of pre-diabetes mellitus (DM) and DM, and its associations with the clinical presentation of tuberculosis (TB).

DESIGN

Screening for DM was conducted among adults (age  18 years) with confirmed TB between December 2013 and January 2017. We used multinomial regression to evaluate the risk factors for pre-DM (glycated hemoglobin [HbA1c]  5.7-6.5% or fasting glucose 100-125 mg/dl) and DM (HbA1c  6.5% or fasting glucose  126 mg/dl or random blood glucose > 200 mg/dl or self-reported DM history/treatment) and the association of dysglycemia with the severity of TB disease.

RESULTS

Among 1793 participants screened, 890 (50%) had microbiologically confirmed TB. Of these, 33% had pre-DM and 18% had DM; 41% were newly diagnosed. The median HbA1c level among newly diagnosed DM was 7.0% vs. 10.3% among known DM (P < 0.001). DM (adjusted OR [aOR] 4.94, 95%CI 2.33-10.48) and each per cent increase in HbA1c (aOR 1.42, 95%CI 1.01-2.01) was associated with >1+ smear grade or 9 days to TB detection.

CONCLUSION

Over half of newly diagnosed TB patients had DM or pre-DM. DM and increasing dysglycemia was associated with higher bacterial burden at TB diagnosis, potentially indicating a higher risk of TB transmission to close contacts.

Tobacco Cessation Programme for Cab Drivers in Mumbai, India and Assessment of Impact of Smoke Free Cabs on Cab Drivers and Commuters

Background: Tobacco epidemic is one of the biggest public health threats, killing nearly seven million people annually. With implementation of smoke free public places legislation, cabs in India are smoke free. However, large majority of the cab drivers are addicted to tobacco. Aim: The aims of the study were to measure cab driver's knowledge, about tobacco, understand pattern of tobacco usage, provide assistance in quitting tobacco, perform oral cancer screening, measure effectiveness of smoking ban in cabs and understand perceptions of cab drivers and commuters to ban. Methods: 400 cab drivers in Mumbai were enrolled after obtaining informed consent. Personal interviews were conducted to understand their knowledge, attitudes and practices regarding tobacco use, smoke free cab policies and their experiences and opinion regarding ban on smoking in cabs. They were offered health education, oral cancer screening and tobacco cessation assistance at regular intervals over a year. Results: 64% cab drivers used tobacco, mainly in smokeless forms (80%). 94% intended to quit, 64% had made previous quit attempts and 70% expressed need of assistance for quitting tobacco. 62% had displayed a No Smoking sign in their cab and 75% expressed full compliance by passengers to the ban. 112 cab drivers had oral precancerous lesions and one cab driver was diagnosed with invasive oral carcinoma. 49% cab drivers quit tobacco and 46% reduced their tobacco consumption by the end of ten months. Conclusion: Smoke free cab policy has increased awareness and reduced passive smoking and this may encourage tobacco users to quit the habit. However, many cab drivers are themselves addicted to tobacco and need professional assistance for quitting. Hence, tobacco cessation - assisting the current users to quit tobacco needs to go hand in hand with smoke free policies. Smoke free cab policies have received enormous support from the cab drivers in Mumbai. There was encouraging compliance to smoke free policies from the commuters. Tobacco quit rate of 49% was achieved by the end of the program.

Household food insecurity is associated with low interferon-gamma levels in pregnant Indian women

SETTING

Over 20% of tuberculosis (TB) cases during pregnancy occur in India.

OBJECTIVE

To determine the association between household food insecurity and interferon-gamma (IFN-γ) levels in pregnancy.

DESIGN

Pregnant women in India were administered the Household Food Insecurity Access Scale (HFIAS) questionnaire and underwent an IFN-γ release assay. Logistic regression was used to identify factors associated with food insecurity.

RESULTS

Of 538 women, 60 (11%) had household food insecurity, 47 (78%) of which were moderate or severe food insecure. After mitogen stimulation, moderate or severe food insecure women had a median IFN-γ concentration of 4.2 IU/ml (IQR 2.2-9.8) vs. 8.4 IU/ml (IQR 3.0-10) in women with no or mild food insecurity (P = 0.03). In multivariate analysis, higher IFN-γ concentrations were associated with human immunodeficiency virus infection (OR 1.3, 95%CI 0.51-2.1, P = 0.001), and inversely associated with moderate or severe food insecurity (OR -1.6, 95%CI -2.9 to -0.27, P = 0.02) and the number of adults in the household (OR -0.08, 95%CI -0.16 to -0.01, P = 0.03). There was no association between food insecurity and IFN-γ response to Mycobacterium tuberculosis antigen.

CONCLUSION

Food insecurity in pregnancy is associated with low IFN-γ levels. There was no association between food insecurity and IFN-γ response to M. tuberculosis antigen, but our study was underpowered to detect this outcome.

Treatment outcomes of daily anti-tuberculosis treatment in HIV-infected patients seeking care at a private clinic in India

SETTING

Little is known about outcomes of patients co-infected with human immunodeficiency virus (HIV) and tuberculosis (TB) who are treated in the private sector in India.

OBJECTIVE

To describe the treatment outcomes of daily anti-tuberculosis treatment (ATT) and their determinants among HIV-TB co-infected patients treated at a private clinic in Pune, India.

DESIGN

Data on adult HIV-TB co-infected patients treated with daily ATT were analysed using logistic regression and Cox model to assess risk factors for default and death.

RESULTS

Of 769 cases, 78% were aged <45 years, 71% were males, 64% had CD4 < 200 cells/mm³, 67% were antiretroviral treatment (ART) naïve at TB diagnosis, 53% had extra-pulmonary TB, and 12% had a past history of TB. ATT was successfully completed by 58.5%, 34.3% defaulted (i.e., discontinued ATT for >2 months) and 3.9% died during ATT. The risk of default was higher among males (aOR 1.67, 95%CI 1.17-2.39), ART-naïve patients (aOR 1.91, 95%CI 1.34-2.73) and those with a past history of TB (aOR 1.86, 95%CI 1.15-3.01). Survival probability at 365 days was 95% (95%CI 93-97). The risk of death was higher among patients with CD4 < 50 cells/mm³ (aHR 4.63, 95%CI 1.47-14.65) than in those with CD4 > 200 cells/mm³.

CONCLUSIONS

Low overall mortality was seen with daily ATT in HIV-TB co-infected patients. High default rates in private facilities warrant urgent attention.

The CFTR gene mild variants poly-T, TG repeats and M470V detection in Indian men with congenital bilateral absence of vas deferens

The aim of the study was to detect the frequency of the CFTR gene variants poly-T, TG repeats and c.1408A>G p.Met470Val (M470V) in Indian men with congenital bilateral absence of the vas deferens (CBAVD). Men diagnosed with CBAVD (n = 76), their female partners (n = 76) and healthy men from general population (n = 50) were recruited. Genomic DNA was isolated and the polymorphic regions of IVS9- c.1210-12T [5] and M470V were amplified using specific primers followed by Sanger's DNA sequencing. A statistically significant increase in the frequency of heterozygous IVS9- c.1210-12T [5] (39.4%) was observed in CBAVD men as compared to controls (14%). The allelic distribution of c.1210-12T [5], c.1210-12T [7] and c.1210-12T [9] in CBAVD men was 21%, 64.4% and 13% and that in healthy controls was 7%, 73% and 20% respectively. Longest TG repeat c.1210-34TG [13] was found in association with c.1210-12T [5] with an allelic frequency of 5.9% in CBAVD men. We found a significant association of c.1210-34TG [12]/c.1210-34TG [13] - c.1210-12[5] -V470 allele in CBAVD men. Twelve female partners harboured a heterozygous c.1210-12T [5] allele. The study emphasises the need to screen both partners for the polymorphisms M470V, poly-T, TG tract repeats in addition to population-specific known CFTR gene mutations.

Mucormycosis of the Frontal Sinus: A Rare Case Report and Review

Mucormycosis of the frontal sinus are rarely seen in day to day clinical practice. Although this fungus is commonly found in the environment, the disease is usually prevented by the immune system and is hence rare. Well-recognized risk factors for the disease include diabetes mellitus, leukemia, aplastic anemia, myelodysplastic syndrome, blood dyscrasias, and immunosuppressive therapy in organ transplantation, renal disease, sepsis, and severe burns. The disease is primarily found in those who are immunocompromised, but it may also manifest in immuno competent persons. Current therapy for the invasive disease includes early surgical debridement, antifungal therapy management of underlying predisposing factors. Early recognition of the disease and treating the underlying cause of mucormycosis, such as diabetes, are key to improving outcomes. The antifungal treatment of choice for mucormycosis is amphotericin B, although very high doses are required because of the relative resistance of the fungus to the drug. Here, we present a case of rhinocerebral mucormycosis of frontal sinus in a diabetic patient, who was managed by systemic antifungals, surgical debridement, and obliteration procedures.

Oro-Nasal Communication

INTRODUCTION

Breach in the palatal vault leading to an abnormal communication between oral and nasal cavity is known as oro-nasal communication. It is an uncommon presentation in day-to-day clinical practice except in some patients of cleft lip and palate.Etiology may be congenital or acquired. Alveolar and palatal cleft defects are the most common etiological factor. The acquired causes may be trauma, periapical pathology, infections, neoplasms, postsurgical complications, and radio and chemo necrosis.Clinical features like nasal regurgitation of food, defective speech, fetid odor, bad taste, and upper respiratory tract and ear infection are associated with oro-nasal communication.Management depends upon the size and site of defect, age of patient, and associated comorbidity. The definitive management is always surgical. Two layered closure provides greater support and stability and reduces the risk of failure. Palatal rotational flaps are suitable for smaller defects. The other local flaps are buccal mucosal flap, tongue flap, and facial artery myomucosal flap. Temporoparietal galeal flap, turbinate flap, free radial forearm flap, and scapular flap have also been successfully used for closure of oronasal communication. Newer procedures like the use of bone morphogenic protein, acellular dermal matrices, human amniotic membrane, and distraction osteogenesis have been tried successfully. The rate of recurrence is high.Unsuccessful surgical attempts and larger defects associated with compromised medical conditions are better managed nonsurgically with obturator incorporating the missing teeth.

Vitamin D deficiency and risk of postpartum tuberculosis among HIV-infected breastfeeding mothers in India

Some studies have associated low vitamin D levels with the risk of tuberculosis (TB), but its association in human immunodeficiency virus (HIV) infected mothers in a TB-endemic region has not been well studied. We conducted a nested 1:2 case-control study among HIV-infected mothers in western India to evaluate the association between maternal vitamin D levels and the risk of postpartum TB. Vitamin D insufficiency, moderate deficiency and severe deficiency were observed in a high proportion of HIV-infected mothers, but were not associated with the risk of postpartum TB.

NGS-based approach to determine the presence of HPV and their sites of integration in human cancer genome

BACKGROUND

Human papilloma virus (HPV) accounts for the most common cause of all virus-associated human cancers. Here, we describe the first graphic user interface (GUI)-based automated tool 'HPVDetector', for non-computational biologists, exclusively for detection and annotation of the HPV genome based on next-generation sequencing data sets.

METHODS

We developed a custom-made reference genome that comprises of human chromosomes along with annotated genome of 143 HPV types as pseudochromosomes. The tool runs on a dual mode as defined by the user: a 'quick mode' to identify presence of HPV types and an 'integration mode' to determine genomic location for the site of integration. The input data can be a paired-end whole-exome, whole-genome or whole-transcriptome data set. The HPVDetector is available in public domain for download: http://www.actrec.gov.in/pi-webpages/AmitDutt/HPVdetector/HPVDetector.html.

RESULTS

On the basis of our evaluation of 116 whole-exome, 23 whole-transcriptome and 2 whole-genome data, we were able to identify presence of HPV in 20 exomes and 4 transcriptomes of cervical and head and neck cancer tumour samples. Using the inbuilt annotation module of HPVDetector, we found predominant integration of viral gene E7, a known oncogene, at known 17q21, 3q27, 7q35, Xq28 and novel sites of integration in the human genome. Furthermore, co-infection with high-risk HPVs such as 16 and 31 were found to be mutually exclusive compared with low-risk HPV71.

CONCLUSIONS

HPVDetector is a simple yet precise and robust tool for detecting HPV from tumour samples using variety of next-generation sequencing platforms including whole genome, whole exome and transcriptome. Two different modes (quick detection and integration mode) along with a GUI widen the usability of HPVDetector for biologists and clinicians with minimal computational knowledge.

Self-care activities among patients with diabetes attending a tertiary care hospital in mangalore karnataka, India

Background:

Increasing prevalence of diabetes in India is resulting in an epidemiological transition. The care of the people with diabetes is traditionally seen as doctor centered, but the concept of self-care of people with diabetes is a new domain and is proven beneficial.

Aim:

The aim was to determine the practice of self-care activities among people with diabetes attending a tertiary care hospital in Mangalore.

Subjects and Methods:

A facility-based cross-sectional study was conducted in Government Wenlock Hospital, Mangalore during September–October 2012. A total of 290 patients with >1-year duration of diabetes mellitus (DM) were asked to respond to summary diabetes self-care activities questionnaire after obtaining the consent from them. The statistical analysis was performed in terms of descriptive statistics and association between the variables was tested using Mann–Whitney U-test.

Results:

A healthy eating plan on a daily basis was followed by 45.9% (133/290) of the participants, daily exercises for 30 min were followed by 43.4% (126/290), and regular blood sugar monitoring was done by 76.6% (222/290). Regarding the adherence to oral hypoglycemic agents and insulin, daily adherence to medication was seen among 60.5% (155/256) and 66.9% (138/206) were found to be adherent to insulin injections on a daily basis.

Conclusions:

Self-care practices were found to be unsatisfactory in almost all aspects except for blood sugar monitoring and treatment adherence. As these practices are essential for prevention of complications and better quality-of -life, more efforts should be put to educate the people with diabetes.

Intramuscular delivery of heterodimeric IL-15 DNA in macaques produces systemic levels of bioactive cytokine inducing proliferation of NK and T cells

Interleukin-15 (IL-15) is a common γ-chain cytokine that has a significant role in the activation and proliferation of T and NK cells and holds great potential in fighting infection and cancer. We have previously shown that bioactive IL-15 in vivo comprises a complex of the IL-15 chain with the soluble or cell-associated IL-15 receptor alpha (IL-15Rα) chain, which together form the IL-15 heterodimer. We have generated DNA vectors expressing the heterodimeric IL-15 by optimizing mRNA expression and protein trafficking. Repeated administration of these DNA plasmids by intramuscular injection followed by in vivo electroporation in rhesus macaques resulted in sustained high levels of IL-15 in plasma, with no significant toxicity. Administration of DNAs expressing heterodimeric IL-15 also resulted in an increased frequency of NK and T cells undergoing proliferation in peripheral blood. Heterodimeric IL-15 led to preferential expansion of CD8⁺NK cells, all memory CD8⁺ T-cell subsets and effector memory CD4⁺ T cells. Expression of heterodimeric IL-15 by DNA delivery to the muscle is an efficient procedure to obtain high systemic levels of bioactive cytokine, without the toxicity linked to the high transient cytokine peak associated with protein injection.

Compliance with iron-folic acid (IFA) therapy among pregnant women in an urban area of south India

BACKGROUND

Anaemia is highly prevalent among pregnant women and iron deficiency is the most important cause. Like many other countries, India has policies to give pregnant women iron supplements. Non-compliance is one important challenging factor in combating anaemia.

OBJECTIVE

To estimate the compliance for IFA tablets among pregnant women and to study the social factors influencing it.

METHODOLOGY

This study included 190 pregnant women seeking ante-natal care in tertiary health Centres in the Mangalore city in South India. After Institutional Ethics Committee (IEC) approval, data was collected by personal interview. Missing ≥2 doses consecutively was considered non-compliance. The data was analyzed using SPSS (Statistical Package for Social Sciences) version 11.5.

RESULTS

The mean age of the study population was 25.8 years (SD: 4.1). Majority of the subjects consumed mixed diet and 72.1% belonged to lower socioeconomic status. Overall, compliance with IFA tablets was 64.7%. Compliance increased with the increase in age, birth order and single daily dose. Forgetfulness and both perceived as well as experienced side effects of IFA therapy were the important factors for non-compliance.

CONCLUSION

There was a moderate level of Compliance towards IFA tablets with key social and demographic factors playing important role.

Modifiable risk factors associated with tuberculosis disease in children in Pune, India

SETTING

India accounts for the largest burden of tuberculosis (TB) worldwide, with 26% of the world's cases.

OBJECTIVE

To assess the association between novel modifiable risk factors and TB in Indian children.

DESIGN

Cases were children aged ≤ 5 years with confirmed/probable TB based on World Health Organization definitions (definition 1). Controls were healthy children aged ≤ 5 years. Logistic regression was performed to estimate the adjusted odds ratio (aOR) of being a TB case given exposure, including indoor air pollution (IAP; exposure to tobacco smoke and/or biomass fuels) and vitamin D deficiency. Cases were re-analyzed according to a new consensus research definition of pediatric TB (definition 2).

RESULTS

Sixty cases and 118 controls were enrolled. Both groups had high levels of vitamin D deficiency (55% vs. 50%, P = 0.53). In multivariable analysis, TB was associated with household TB exposure (aOR 25.41, 95%CI 7.03-91.81), household food insecurity (aOR 11.55, 95%CI 3.33-40.15) and IAP exposure (aOR 2.67, 95%CI 1.02-6.97), but not vitamin D deficiency (aOR 1.00, 95%CI 0.38-2.66). Use of definition 2 reduced the number of cases to 25. In multivariate analysis, TB exposure, household food insecurity and IAP remained associated with TB.

CONCLUSIONS

Household TB exposure, exposure to IAP and household food insecurity were independently associated with pediatric TB.

Impact of maternal hepatitis B virus coinfection on mother-to-child transmission of HIV

OBJECTIVES

Despite high hepatitis B virus (HBV) endemicity in various resource-limited settings (RLSs), the impact of maternal HIV/HBV coinfection on infant health outcomes has not been defined. We aimed to assess the prevalence of HBV coinfection among HIV-infected pregnant women and its impact on HIV transmission and infant mortality.

METHODS

In this study, the seroprevalence of HBV coinfection was determined among HIV-infected pregnant women enrolled in the Six-Week Extended-Dose Nevirapine (SWEN) India trial. The impact of maternal HIV/HBV coinfection on mother-to-child transmission (MTCT) of HIV and infant mortality was assessed using univariate and multivariate logistic regression analysis.

RESULTS

Among 689 HIV-infected pregnant Indian women, 32 (4.6%) had HBV coinfection [95% confidence interval (CI) 3.4%, 5.3%]. HBV DNA was detectable in 18 (64%) of 28 HIV/HBV-coinfected women; the median HBV viral load was 155 copies/mL [interquartile range (IQR) < 51-6741 copies/mL]. Maternal HIV/HBV coinfection did not increase HIV transmission risk [adjusted odds ratio (aOR) 1.06; 95% CI 0.30, 3.66; P = 0.93]. Increased odds of all-cause infant mortality was noted (aOR 3.12; 95% CI 0.67, 14.57; P = 0.15), but was not statistically significant.

CONCLUSIONS

The prevalence of active maternal HBV coinfection in HIV-infected pregnant women in India was 4.6%. HIV/HBV coinfection was not independently associated with HIV transmission.

Compliance with iron-folic acid (IFA) therapy among pregnant women in an urban area of south India

BACKGROUND

Anaemia is highly prevalent among pregnant women and iron deficiency is the most important cause. Like many other countries, India has policies to give pregnant women iron supplements. Non-compliance is one important challenging factor in combating anaemia.

OBJECTIVE

To estimate the compliance for IFA tablets among pregnant women and to study the social factors influencing it.

METHODOLOGY

This study included 190 pregnant women seeking ante-natal care in tertiary health centres in the Mangalore city in south India. After Institutional Ethics Committee (IEC) approval, data was collected by personal interview. Missing >2 doses consecutively was considered non-compliance. The data was analyzed using SPSS (Statistical Package for Social Sciences) version 11.5.

RESULTS

The mean age of the study population was 25.8 years (SD: 4.1). Most of the subjects consumed mixed diet and 72.1% belonged to lower socioeconomic status. Overall, compliance with IFA tablets was 64.7%. Compliance increased with the increase in age, birth order and single daily dose. Forgetfulness and both perceived as well as experienced side effects of IFA therapy were the important factors for non-compliance.

CONCLUSION

There was a moderate level of compliance towards IFA tablets with key social and demographic factors playing an important role.

Perceptions and preferences of medical students regarding teaching methods in a Medical College, Mangalore India

INTRODUCTION

In the complex setting of a medical school it becomes essential to utilize an approach to teaching and learning that is best suited to the needs of the students. In developing countries like India, where there is an exponential increase of institutions catering to medical students, it becomes a challenge to teach to large number of students per class. Hence, research is needed to identify the needs of students in relation to their day to day learning activities.

OBJECTIVES

To understand the preferences and perception of medical students about the current methods of teaching, aids used for teaching and also identify barriers in learning as perceived by the students.

METHOD

A Cross-sectional study was carried out at Kasturba Medical College, Mangalore during May 2012. Study participants included 2(nd) and 3(rd) year medical students. A semi-structured questionnaire was used to collect the information in relation to preferences and perceptions regarding teaching methods utilized for theory and clinical teaching. SPSS version 11.5 was used for analysis of data. The association between variables of interest was tested using Chi-square test.

RESULTS

A total of 286 students (56.6 % females and 43.4% males) participated with a dropout rate of 10.6%. The study revealed that 71.3% of the students had an attendance above 75%. The most preferred teaching method was Problem Based Learning (PBL) (71.4%) as students felt that it enhanced lateral thinking while Didactic Lectures was the least preferred (32.8%). The most preferred modality of teaching aid was found to be Black board preferred by 46.9% students. In learning rare signs and cases, students preferred video lectures (41%) and mannequins (75.9%) in learning clinical skills. The main barrier in theory learning identified was inappropriate teaching methods (15%) and being new to clinical posting (38.5%) in case of learning clinical skills.

CONCLUSION

The findings of the study suggest that a combination of traditional methods with other methods such as PBL, video lectures and mannequins could be an effective way of teaching theory and clinical skills.

Sputum collection and disposal among pulmonary tuberculosis patients in coastal South India

BACKGROUND

Safe sputum disposal practices minimise the spread of pulmonary tuberculosis (PTB).

OBJECTIVES

To study the perceptions and practices of sputum disposal among PTB patients.

METHODOLOGY

This study was conducted among 206 diagnosed sputum-positive TB patients registered in selected DOTS centres in Mangalore.

RESULTS

Safe sputum disposal practice was followed by 50% of the subjects: it was higher among females (62%), patients of middle socio-economic status (75.5%) and those with a family history of TB (70%). Furthermore, 75% patients believed that TB was caused by several factors.

CONCLUSIONS

High proportions of subjects were unaware about the causes of TB and did not practise safe disposal of sputum.

Correlation of clinical and histopathological classification of leprosy in post elimination era

Clinical and histopathological correlative study was carried out in 171 cases of leprosy using the criteria laid down by Ridley and Jopling. There was male preponderance in the study with majority of patients (35.7%) in the age goup of 21-30 years. The overall concordance between the clinical and histopathological diagnosis was 57.3%. Maximum concordance was seen in the polar ends of the spectrum with 76.9% in LL and 75.0% in TT. The concordance rate was lower in the borderline groups with 57.3% in BT, 40.0% in BL and least concordance of 16.7% in BB. However the concordance for IL was higher than the borderline groups with 66.7%. Cases in borderline group are in continuously changing immunological spectrum. Histological classification because of its definitive features gives a better indication than clinical classification for any recent shift of a case in the spectrum. Therefore skin biopsy should be done in all cases for correct classification of leprosy.