A comparative clinical study of methylprednisolone with ondansetron versus ramosetron in preventing postoperative nausea and vomiting in patients undergoing middle-ear surgeries

Background:

One of the most troublesome complications after middle-ear surgeries has been postoperative nausea and vomiting (PONV). A notable decrease in PONV has been observed with the use of 5-hydroxytryptamine type 3 receptor antagonists and glucocorticoids.

Aim:

This study aimed to evaluate the effectiveness of the combination of intravenous methylprednisolone and ondansetron with ramosetron alone in preventing PONV in patients undergoing middle-ear surgeries.

Settings and Design:

This was a prospective, randomized, double-blind study that comprised sixty patients in the age group of 18–60 years belonging to the American Society of Anesthesiologists (ASA) physical status classification I or II and undergoing middle-ear surgery.

Materials and Methods:

With the help of computer-generated randomization table, sixty patients in the age group of 18–60 years belonging to ASA physical status classification I or II and undergoing middle-ear surgery were randomly allotted to receive a combination of methylprednisolone 40 mg (given at the beginning of surgery) and ondansetron 4 mg (given near the end of surgery) (Group MO, n = 30) or ramosetron 0.3 mg (near the end of surgery) (Group R, n = 30). In both the groups, the incidence of PONV was studied.

Statistical Analysis:

Chi-square test or Fisher's exact test was utilized to analogize the categorical variables. Independent t-test was utilized to analogize the continuous variables.

Results:

In the first 2 h after the surgery, the difference between the two groups regarding the incidence of PONV was insignificant. Between 2 h and 24 h, the incidence of nausea was lowered significantly in the group MO compared to the group R (P = 0.01). Between 24 h and 48 h, the incidence of nausea was more in group R compared to the combination therapy group, which was statistically significant.

Conclusion:

The combination therapy is better than ramosetron alone for the prevention of PONV after middle-ear surgery. Therefore, we advocate a combination of methylprednisolone and ondansetron for prophylaxis for PONV in middle-ear surgeries.

Effect of retinol in the vitrification medium on viability of vitrified ovine preantral follicles and expression of key developmental and apoptosis related genes

BACKGROUND

Vitrification increases the production of reactive oxygen species (ROS) and the antioxidants in the vitrification solution may be beneficial by reducing excessive ROS production.

OBJECTIVE

To evaluate the effect of retinol supplementation in vitrification solution on viability, apoptosis and development-related gene expression in vitrified sheep preantral follicles.

MATERIALS AND METHODS

Preantral follicles were isolated and randomly assigned into one of five groups: Group1, control fresh preantral follicles; Group 2, vitrification treatment; Group 3, vitrification + 2 μM retinol; Group 4, vitrification + 5 μM retinol; Group 5, vitrification + 10 μM retinol. Preantral follicles were placed in vitrification solutions and then plunged into liquid nitrogen (-196°C). After a week, the follicles were thawed and analyzed for follicular viability by trypan blue exclusion method and for gene expression.

RESULTS

Vitrification with 5 μM retinol positively affected viability in comparison with vitrification without retinol (P < 0.05). There was no significant difference in viability among the Group 1, Group 2, Group 3 and Group 5. Expression of apoptotic genes BAX and Casp 3 were higher in the vitrified group, and vitrification with 5 μM retinol (Group 4) is comparable to the control fresh. Expressions of other apoptosis-related genes (i.e., BCL2L1, BAD and BAK) showed significant difference between the control fresh group and the vitrification group with 5 μM retinol. Expression of Annexin5 was also significantly different among various groups. The expression of development competence genes GDF-9 and BMP-15 were higher (P < 0.05) in the Group vitrified with 5 μM retinol.

CONCLUSION

The supplementation of 5 μM retinol in vitrification solution was beneficial for the vitrification of ovine preantral follicles.

Effect of retinol as antioxidant on the post-thaw viability and the expression of apoptosis and developmental competence-related genes of vitrified preantral follicles in buffalo (Bubalus bubalis)

The present study evaluated the effect of supplementation of retinol in the vitrification solution on the viability, apoptosis and development-related gene expression in vitrified buffalo preantral follicles. Preantral follicles isolated from cortical slices of ovaries were randomly assigned into three groups: Group1-Control fresh preantral follicles; Group 2-Vitrification treatment (Vitrification solution 1 (VS1) -TCM-199 + 25 mM HEPES + Foetal bovine serum (FBS) 10%, Ethylene glycol (EG): 10%, Dimethyl sulphoxide (DMSO): 10%, Sucrose-0.3 M for 4 min; VS2- TCM-199 + 25 mM HEPES + FBS10%, EG:25%, DMSO: 25%, Sucrose:0.3 M for 45 s); Group3-vitrification treatment +5 μM of Retinol. Preantral follicles were placed in corresponding vitrification medium and plunged into liquid nitrogen (-196°C). After a week, the follicles were thawed and analysed for follicular viability and gene expression. There was no significant difference in the viability rates among the Group 1(Fresh preantral follicles) (91.46 ± 2.39%), Group 2 (89.59 ± 2.46%) and Group 3 (87.19 ± 4.05%). There was a significantly (p < .05) higher mRNA expression of BCL2L1, GDF-9 and BMP-15 in the vitrification + retinol group compared with the control group. There was a significantly (p < .05) higher expression of Caspase-3 and Annexin-5 in the vitrification group and Vitrification + retinol group compared with control group of follicles. It is concluded that the supplementation of 5 μM of Retinol in Vitrification solution was an efficient vitrification procedure for the vitrification of buffalo preantral follicles.

Comparison of Different Doses of Clonidine as an Additive to Intrathecal Isobaric Levobupivacaine in Patients Undergoing Infraumbilical Surgeries

Background:

Spinal anesthesia is a safe, reliable, and inexpensive technique with the advantage of providing surgical anesthesia and prolonged postoperative pain relief, and it also blunts autonomic, somatic, and endocrine responses to surgical stimulus.

Aim:

The aim of this study was to assess the efficacy 15 μg and 30 μg of intrathecal clonidine along with 3 mL of 0.5% isobaric levobupivacaine in comparison with plain 0.5% isobaric levobupivacaine.

Setting and Design:

The prospective, interventional, randomized, comparative, double-blinded study was conducted after obtaining approval from the institutional ethical committee.

Materials and Methods:

Seventy-five patients posted for elective lower-limb orthopedic surgeries were randomly divided into three groups with 25 patients in each group as L (levobupivacaine 0.5%), LC-15 (levobupivacaine 0.5% + clonidine 15 μg), and LC-30 (levobupivacaine 0.5% + clonidine 30 μg). All the patients were given spinal anesthesia using the study drugs, and various parameters were monitored.

Statistical Analysis:

The three groups were compared statistically using analysis of variance and Student's t-test (independent samples t-test). P < 0.05 was considered statistically significant.

Results:

There was a statistically significant difference among the three groups with respect to the onset of time for maximum sensory blockade and duration of analgesia. A statistically significant difference was noted among the three groups with respect to the onset of time for maximum motor blockade.

Conclusion:

Both doses of clonidine produced prolonged sensory block compared to the control. It has been found that 30 μg of clonidine as an adjuvant has produced faster onset and prolonged duration sensory block compared to 15 μg of clonidine.

Older age and duration of exposure to type 2 diabetes in selective screening of asymptomatic carotid artery stenosis for primary stroke prevention-A single institution experience

AIMS

To evaluate the incidence and risk factors for carotid artery stenosis amongst asymptomatic type 2 diabetes from a single Malaysian tertiary institution.

METHODS

This is a prospective cross-sectional study of asymptomatic type 2 diabetics selected from the outpatient ophthalmology and endocrine clinics for carotid duplex ultrasound scanning performed by a single radiologist. The duplex ultrasound criteria were based on the North American Symptomatic Carotid Endarterectomy Trial (NASCET) classification of carotid artery stenosis. Univariate and multivariate analysis was performed to identify possible risk factors of carotid artery stenosis.

RESULTS

Amongst the 200 patients, the majority were males (56%) and Malay predominance (58.5%). There were 12/200 patients (6%) with mean age of 69.2 years identified to have carotid artery stenosis. Univariate analysis of patients with asymptomatic carotid artery stenosis identified older age of 69.2 years (p=0.027) and duration of exposure to diabetes of 17.9 years (p=0.024) as significant risk factors.

CONCLUSION

Patients with longer exposure of diabetes and older age were risk factors of carotid artery stenosis in asymptomatic type 2 diabetics. These patients should be considered for selective screening of carotid artery stenosis during primary care visit for early identification and closer surveillance for stroke prevention.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Unexpected complication of arteriovenous fistula of the left common carotid to internal jugular vein following central venous catheterization

Incidence of inadvertent arterial puncture secondary to central venous catheter insertion is not common with an arterial puncture rate of <1%. This is due to the advancements and wide availability of ultrasound to guide its insertion. Formation of arteriovenous fistula after arterial puncture is an unexpected complication. Till date, only five cases (including this case) of acquired arteriovenous fistula formation has been described due to inadvertent common carotid puncture. The present case is a 26-year-old man sustained traumatic brain injuries, chest injuries and multiple bony fractures. During resuscitative phase, attempts at left central venous catheter via left internal jugular vein under ultrasound guidance resulted in inadvertent puncture into the left common carotid artery. Surgical neck exploration revealed that the catheter had punctured through the left internal jugular vein into the common carotid artery with formation of arteriovenous fistula. The catheter was removed successfully and common carotid artery was repaired. Postoperatively, the patient recovered and clinic visits revealed no neurological deficits. From our literature review, the safest method for removal is via endovascular and open surgical removal. The pull/push technique (direct removal with compression) is not recommended due to the high risk for stroke, bleeding and hematoma formation.

Factors, mechanisms and implications of chromatin condensation and chromosomal structural maintenance through the cell cycle

A series of well-orchestrated events help in the chromatin condensation and the formation of chromosomes. Apart from the formation of chromosomes, maintenance of their structure is important, especially for the cell division. The structural maintenance of chromosome (SMC) proteins, the non-SMC proteins and the SMC complexes are critical for the maintenance of chromosome structure. While condensins have roles for the DNA compaction, organization, and segregation, the cohesin functions in a cyclic manner through the cell cycle, as a "cohesin cycle." Specific mechanisms maintain the architecture of the centromere, the kinetochore and the telomeres which are in tandem with the cell cycle checkpoints. The presence of chromosomal territories and compactness differences through the length of the chromosomes might have implications on selective susceptibility of specific chromosomes for induced genotoxicity.

Upper Gastrointestinal Bleeding in Aluminium Phosphide Poisoning

Aluminium phosphide is one of the most common poisons used for suicide in an agricultural country like India. Death is usually due to myocarditis which occurs within few hours of ingestion. There are many late complications reported in medical literature, however toxic effects on the gastrointestinal system, particularly corrosive action leading to massive haemorrhage is rarely reported. A 30 year old male developed upper gastrointestinal bleeding on the second day after consumption of aluminium phosphide. An exploratory laprotomy was done followed by adhesinolysis, gastrostomy closure with feeding jejunostomy and drainage. He died after eight days of ingestion. The autopsy findings of this rarely reported case along with review of literature on corrosive action of Aluminium Phosphide is discussed.

Significance of Crime Scene Visit by Forensic Pathologist in Cases of Atypical Firearm Injuries

Deaths due to firearms are some of the interesting and contentious cases that a forensic pathologist/autopsy surgeon encounters in his practice. Whenever there is 'ambiguity' regarding the nature or sequence of events any unnatural deaths including those caused by firearms the practice of visiting crime scene should be encouraged especially in a country like India where autopsy surgeons often neglect it. Here we present a case report in which there were inconsistencies in the autopsy findings with the alleged history. The witnesses heard about four to six gunshot sounds, whereas only two spent cartridge cases were retrieved from the crime scene. Authors identified the atypical nature of firearm injuries sustained by the victims that were possible by just two bullets. Crime scene visit was undertaken where we discovered the possibility of the echo effect behind the production of four to six sounds. Further by using computer software program, positions of the gunman, victims and the bullet trajectory of the two bullets was created.

Hypermobility syndrome

Three cases of Hypermobility Syndrome (HS) are discussed. The first case was a young female, aged 24, with musculoskeletal symptoms since 5 years. Second was an 18 year old male with similar symptoms since 3 years. The third was an elderly female who presented with knee joint osteoarthritis (OA) and apparent but reducible deformities of hands mimicking rheumatoid arthritis (RA). All three patients had hypermobility of joints in absence of demonstrable systemic rheumatic disease. The prevalence, clinical features and management of the entity is discussed. An increased awareness of this condition among physicians is warranted as some patients may be erroneously diagnosed as RA/SLE and may be put on DMARDs and steroids.

Ilaprazole: Is this a superior proton pump inhibitor for duodenal ulcer?

BACKGROUND

Preclinical studies have found ilaprazole to be significantly effective in preventing the development of reflux oesophagitis and gastric secretion in a dose-dependent manner; the drug also has a broad dose range and safety feature. Till date only one clinical study on patients with gastro-oesophageal reflux disease has shown its potency in suppressing gastric acid secretion.

OBJECTIVES

To review the published randomized controlled trials (RCTs) assessing the efficacy of ilaprazole in duodenal ulcer (DU) compared to other available proton pump inhibitors (PPI).

METHODS

RCTs comparing ilaprazole with other PPIs in DU were searched in the PubMed and Cochrane Library database using the term 'ilaprazole and duodenal ulcer'. All clinical studies showing effectiveness of ilaprazole in patients with DU, either full texts or scientific abstracts and found to be potentially eligible for the systematic review, were included and evaluated.

RESULTS

Four RCTs having follow-up data were included. A total of 1077 patients with DU were assessed. All the trials had included omeprazole as a comparator PPI. The majority of patients (80%) became asymptomatic after treatment in both the groups. None of the trials data predict ilaprazole to be superior to omeprazole in terms of efficacy in patients with DU.

CONCLUSION

The trials conducted were limited in numbers and all the trial data indicated the efficacy of ilaprazole to be similar to that of omeprazole. None of the trials indicated superiority of ilaprazole over the existing PPIs.

Risk factors, preemptive therapy, and antiperistaltic agents for Clostridium difficile infection in cancer patients

BACKGROUND

Clostridium difficile infection (CDI) is a serious complication of chemotherapy including high-dose regimens with autologous stem cell transplantation (ASCT). Antiperistaltic agents are contraindicated in CDI and preemptive CDI therapy is not recommended. We assessed the incidence, risk factors, and outcomes of CDI in patients with newly diagnosed multiple myeloma (MM) receiving similar antineoplastic therapy and supportive care including antiperistaltic agents and preemptive CDI antibiotics for significant diarrhea.

METHODS

A total of 303 consecutive MM patients (2004-2007) were enrolled in a protocol consisting of induction chemotherapy, tandem melphalan (MEL)-ASCT, and consolidation. Patients with grade 2-4 diarrhea were simultaneously tested for CDI, and initiated on antiperistaltic agents (loperamide) and preemptive anti-CDI therapy. Risk factors, including prior CDI and MM immunoglobulin (Ig) isotype, were evaluated. Multinomial logistic regression was used to compute the relative risk ratio (RRR) and 95% confidence intervals (CIs).

RESULTS

There were 43 cases of CDI (14.2%) during 1529 chemotherapy courses (536 ASCT). IgA MM protected against CDI (RRR 0.35; 95% CI 0.13-0.93, P = 0.04) whereas CDI during first induction markedly increased the risk of recurrence during second induction (RRR = 10.94; 95% CI 1.90, 62.92, P = 0.01) and following MEL-ASCT (RRR = 6.63; 95% CI 1.51, 29.12, P = 0.01). No CDI-related surgical intervention or death ensued despite use of antiperistaltic agents.

CONCLUSIONS

CDI was not uncommon in cancer patients receiving chemotherapy. IgA myeloma appears to be protective. Concurrent antiperistaltic (loperamide) and preemptive CDI therapies were associated with excellent outcomes. Prior CDI history increased the risk for recurrence during successive chemotherapy courses.

Genetic K-means algorithm

In this paper, we propose a novel hybrid genetic algorithm (GA) that finds a globally optimal partition of a given data into a specified number of clusters. GA's used earlier in clustering employ either an expensive crossover operator to generate valid child chromosomes from parent chromosomes or a costly fitness function or both. To circumvent these expensive operations, we hybridize GA with a classical gradient descent algorithm used in clustering, viz. K-means algorithm. Hence, the name genetic K-means algorithm (GKA). We define K-means operator, one-step of K-means algorithm, and use it in GKA as a search operator instead of crossover. We also define a biased mutation operator specific to clustering called distance-based-mutation. Using finite Markov chain theory, we prove that the GKA converges to the global optimum. It is observed in the simulations that GKA converges to the best known optimum corresponding to the given data in concurrence with the convergence result. It is also observed that GKA searches faster than some of the other evolutionary algorithms used for clustering.

Celiac crisis in a patient with chronic lymphocytic leukemia and hypogammaglobulinemia

Celiac crisis is an acute, fulminant form of celiac disease manifesting with severe diarrhea, metabolic and electrolyte abnormalities, and weight loss. It is mostly seen in children, and there are very few reports in adults. We present a 67-year-old patient with chronic lymphocytic leukemia (CLL) who presented with weight loss of 40 pounds, severe diarrhea, hypoalbuminemia and hypokalemia. The patient was immunosuppressed with hypogammaglobulinemia, which is common in CLL. Thus, the patient had negative serological studies for celiac disease. An endoscopic evaluation and HLA typing supported the diagnosis of celiac disease. Although the differential diagnosis was broad, exclusion of other etiologies for diarrhea, prompt diagnosis of celiac disease and initiation of gluten-free diet resolved the crisis. This is the first such report of a patient presenting with celiac crisis on a background of hypogammaglobulinemia.

Laparoscopic emergency and elective surgery for ulcerative colitis

OBJECTIVE

To analyse surgical outcomes of fulminate and medically resistant ulcerative colitis (UC) carried out laparoscopically.

METHOD

A prospective database identified 69 consecutive patients who underwent surgery for UC under the senior author over a 5-year period to April 2006.

RESULTS

Thirty-two patients (18 male patients), median BMI 26, underwent laparoscopic subtotal colectomy (LSTC): 22 acute emergencies, 10 refractory to medical therapy and unfit for restorative proctocolectomy. All were receiving iv steroids; azathioprine (7), cyclosporin (5). The median operation time was 135 min (65-280). There was one conversion. Twenty-nine patients have subsequently undergone completion proctectomy and W-pouch formation [24 patients were performed laparoscopically - laparoscopic completion proctectomy (LCP)]; widespread adhesions precluded in five patients. Twenty-six patients underwent restorative laparoscopic proctocolectomy (LRP) - one conversion. Twenty patients underwent W-pouch reconstruction via a Pfannenstiel incision. Six J-pouches were constructed and returned via the ileostomy site. Three underwent a laparoscopic pan-proctocolectomy (LPPC); one conversion. Eight patients underwent open STC. The median time to normal diet was 48 h (1-7 days) for LSTC/LCP and 36 h (1-5 days) for LRP. There were two major complications following LRP, two following LSTC, one following LCP, one following LPPC and five following open surgery. Median hospital stay was 8 days (6-72) for LSTC, 7 days (6-9) for LCP and 5 days (3-45) for LRP. There were six 30-day readmissions following laparoscopic surgery (DVT, reactive depression, ileostomy hold up (2), abdominal pain and high output ileostomy).

CONCLUSION

Laparoscopic subtotal and restorative proctocolectomies in fulminate and medically resistant UC are feasible, safe and largely predictable operations that allow for early hospital discharge. Laparoscopic colectomy facilitates subsequent proctectomy and pouch construction.

Randomized clinical trial of the effect of quilting latissimus dorsi flap donor site on seroma formation

Background

Latissimus dorsi (LD) flap breast reconstruction is associated with a high incidence of donor site seromas, despite the use of surgical drains. The aim of this study was to evaluate the use of donor site quilting sutures, as well as drains, on the incidence, volume and frequency of seroma aspiration.

Methods

The trial randomized 108 women undergoing LD breast reconstruction to quilting procedures (54) or control group (52) for intention-to-treat analysis; two were excluded. Outcome measures were the incidence and volume of postoperative seroma. Secondary outcome measures included postoperative back pain, analgesic consumption, shoulder movement and duration of hospital stay.

Results

Quilting significantly reduced the overall incidence of seroma from 46 of 48 (96 per cent) to 43 of 52 (83 per cent) (P = 0·036), including the 38 women who had extended LD flap (with or without implants). There were further significant reductions in seroma volume (P = 0·004), frequency of aspiration (P = 0·001) and overall seroma volumes, including surgical drainage and symptomatic seromas (P = 0·013). Subset analyses for LD–implant (60 women) and extended LD (with or without implant) showed similar significance. Quilting did not affect back pain or compromise shoulder mobility.

Conclusion

Quilting significantly reduced overall seroma volumes after LD breast reconstruction including extended LD, and is recommended in combination with surgical drains.

QSAR studies of N1-(5-chloro-2-pyridyl)-2-{[4-(alkyl methyl)benzoyl]amino}-5-chlorobenzamide analogs

Factor X(a) has materialized as a key enzyme for the intervention of blood coagulation cascade and for the development of new antithrombotic agents. It is the lone enzyme that is responsible for the production of thrombin and is therefore an attractive target for the control of thrombus formation. The biological activities (log1/IC(50)) of anthranilamide-based factor X(a) inhibitors were quantitatively analyzed in terms of physicochemical parameters by the regression analysis. Structural requirements for maximal potency were derived from the results of a quantitative structure activity relationship analysis. The leave-one-out cross-validation method was used to judge the predictive power of final equations.

Synthesis of silica nanotubes from kaolin clay

Silica nanotubes were synthesized from kaolin clay using surfactant intercalation, sulfuric acid and hydrothermal treatments.

Subungual malignant melanoma

A rare case of subungual malignant melanoma in a 43-year-old male, with black dystrophic left middle finger nail plate with positive Hutchison sign is presented. Patient underwent disarticulation at the proximal interphalangeal joint. Histopathology confirmed malignant melanoma, and resection free of tumour cells.

Very active CeO2-zeolite catalysts for NOx reduction with NH3

Selective catalytic reduction of NO with NH3 over high weight percentage CeO2-zeolites showed excellent NOx conversions at very high space velocities under simulated exhaust gas conditions in the presence of H2O.

Selective catalytic reduction of NOx with propene over CeO2-ferrierite

CeO2-HFerrierite catalysts, prepared by physically mixing the components, showed very high conversions of NO under dry and wet conditions and excellent regeneration properties of the coked catalyst in the presence of water.

Tuberculous panniculitis

A rare case of tuberculous panniculitis in a 2-year-old girl who presented with a progressively increasing large nodular plaque over the back of 2 months duration is being reported. Diagnosis was confirmed histopathologically and on the basis of a positive accelerated BCG test.

A clinico-pathological study of 70 cases of pemphigus

A clinicopalhological study of 70 cases of pemphigus observed over a span of four and a half years from January 1992 to June 1996 at the Sir J.J. Group of Hospitals and Grant Medical College, Mumbai is reported. Pemphigus vulgaris constituted the single largest group of 43 cases, followed by pemphigus foliaceus (25 cases) and pemphigus vegetans (2 cases). Majority of the cases were seen in the age group of 21-60 years, with a slight male predominance. The youngest patient was 14 years while the eldest was aged 75 years. Mucosal involvement was seen in 31 cases of pemphigus vulgaris, as opposed to only 5 cases of pemphigus foliaceus. Flaccid bullae were present in 100% cases. Pruritus was complained of in 14 cases, though it was more common in pemphigus vegetans and vulgaris. Salient histopathological features of pemphigus vulgaris observed were (I) intraepidermal suprabasal blisters (35 cases), (2) presence of acantholytic cells (40 cases), (3) "Row of tombstone appearance" (I8 cases) and (4) acantholysis involving follicular sheath (20 cases). Main histopathological features of pemphigus foliaceus were (1) subcorneal blister (15 case), (2) acantholysis (24 cases) and (3) bulla cavity containing inflammatory infiltrate (12 cases). Both cases of pemphigus vegetans showed hyperkeratosis, papillomatosis and irregular acanthosis with intra-epidermal eosinophilic abscesses besides suprabasal lacunae.

Dermatitis herpetiformis intolerant to dapsone in Aids

A 35-year-old man with AIDS and pulmonary tuberculosis presented with lesions suggestive of dermatitis herpetiformis and intolerance to dapsone. He was managed successfully with a combination of nicotinamide 200 mg/day and indomethacin 75 mg/day, topical steroids and gluten free diet.

Retinoblastoma with skin metastasis

A rare case of bilateral retinoblastoma with cutaneous metastases in a 10-month-old male child with a rapidly fulminant course is being reported.

Skin manifestations of acromegaly - a study of 34 cases

The common dermatological manifestations seen in 34 cases of acromegaly were changes in facial appearance, enlargement of hands and feet, intolerance to heat and sweating, carpal tunnel syndrome, hirsutism, acrochordons and acanthosis nigricans. The mean estimated age of onset was 32.8 years in males and 31.7 years in females, while the mean age at the time of diagnosis was 38.6 years and 36.1 years for males and females respectively, with a slight male preponderance noted.

Cockayne's syndrome

A 10-year old boy, a product of consanguineous marriage was diagnosed clinically as a case of Cockayne's syndrome because of delayed milestones, deaf mutism with spastic paraplegia, dwarfism, salt and pepper fundus, typical facies and a photosensitive rash on the butterfly area of the face.

Mikulicz's syndrome

A rare case of Mikulicz's syndrome with underlying tuberculosis in a 65-year old male with bilaterally symmetrical, asymptomatic enlargement of parotid, submandibular and lacrimal glands is reported.