The impact of hospitalization on mortality in patients with connective tissue disease-associated interstitial lung disease: a medical records review study

Abstract Background Interstitial lung disease (ILD) remains one of the most important causes of morbidity and mortality in patients with Connective Tissue Diseases (CTD). This study evaluated the impact of hospitalization on mortality in an ethnically and racially diverse cohort of CTD-ILD patients. Methods We conducted a medical records review study at Montefiore Medical Center, Bronx, NY. We included 96 patients and collected data on demographic characteristics, reasons for hospitalization, length of stay, immunosuppressant therapy use, and mortality. We stratified our patients into two cohorts: hospitalized and nonhospitalized. The hospitalized cohort was further subdivided into cardiopulmonary and non-cardiopulmonary admissions. Two-sample tests or Wilcoxon's rank sum tests for continuous variables and Chi-square or Fisher's exact tests for categorical variables were used for analyses as deemed appropriate. Results We identified 213 patients with CTD-ILD. Out of them, 96 patients met the study's inclusion criteria. The majority of patients were females (79%), and self-identified as Hispanic (54%) and Black (40%). The most common CTDs were rheumatoid arthritis (RA) (29%), inflammatory myositis (22%), and systemic sclerosis (15%). The majority (76%) of patients required at least one hospitalization. In the non-hospitalized group, no deaths were observed, however we noted significant increase of mortality risk in hospitalized group (p = 0.02). We also observed that prolonged hospital stay (> 7 days) as well as older age and male sex were associated with increased mortality. Conclusion Prolonged (> 7 days) hospital stay and hospitalization for cardiopulmonary causes, as well as older age and male sex were associated with an increased mortality risk in our cohort of CTD-ILD patients.

Carga económica de la hipercolesterolemia en población con alto riesgo cardiovascular en México / Economic burden of hypercholesterolemia in high risk of cardiovascular disease population in Mexico

Resumen Objetivo: Se estimó la carga económica directa e indirecta de la hipercolesterolemia en población con alto riesgo de presentar un evento cardiovascular. Para ello se definieron específicamente cinco grupos de pacientes: 1) aquellos con hipercolesterolemia familiar; 2, 3 y 4) personas con hipercolesterolemia más el antecedente de diabetes, infarto o evento vascular cerebral; 5) pacientes con hipercolesterolemia más diabetes y antecedente de infarto agudo de miocardio (definidos como pacientes de muy alto riesgo cardiovascular). Los cálculos se hicieron desde la perspectiva de las instituciones de salud pública en México. Método: Para la estimación de los costos directos se incluyó la atención ambulatoria, el tratamiento farmacológico, la atención hospitalaria y las intervenciones quirúrgicas relacionadas con las enfermedades cardiovasculares. Para la carga económica indirecta, se consideraron las muertes reportadas específicamente por causa de hipercolesterolemia, en un momento anterior al final de la edad productiva (muerte prematura). Resultados: La carga económica directa de las cinco categorías de pacientes en riesgo consideradas es de MXN $39,601,464,154 (USD $1,987,526,432), mientras que la carga económica indirecta asciende a MXN $121,646,689 (USD $6,105,229). Conclusiones: El impacto económico de la hipercolesterolemia en población con alto riesgo cardiovascular correspondía a $39,723,110,843 en 2020 (equivalente a USD $1,993,631,661), equivalente al 0.16% del PIB nacional.

Abstract Objective: To estimate the direct and indirect economic burden of hypercholesterolemia in patients with high risk of a cardiovascular event, specifically there were defined 5 groups of patients: 1) familial hypercholesterolemia; 2, 3 and 4) patients with hypercholesterolemia and background of diabetes, myocardial infarction or stroke; 5) diabetes, myocardial infarction and hypercholesterolemia (very high-risk patients) from the Mexican public healthcare institutions. Methods: For the estimation of the direct costs the items included correspond to: outpatient care, pharmacological treatment, inpatient hospital care, and surgical procedures. For indirect economic burden, death certificates, before the end of the productive age due to hypercholesterolemia were calculated (premature mortality). Results: The direct economic burden for the 5 groups of patients at risk is MXN $39,601,464,154 (USD $1,987,526,432), while the indirect economic burden amounts to MXN $121,646,689 (USD $6,105,229). Conclusions: The economic impact of hypercholesterolemia in patients with high cardiovascular risk is $39,723,110,843 (equivalent to USD $1,993,631,661) and corresponds to the 0.16% of GDP.

Total Bilateral Extraperitoneal Varicocelectomy with Hernioplasty

A varicocele is a dilation of veins within the pampiniform plexus and affects 15% of males worldwide. It often occurs during puberty and gets worse with age. There are 3 grades of varicoceles. Grade 1 and 2 varicoceles are tiny and challenging to find without the help of a medical expert. Varicoceles of grade 3 are easily palpable and frequently visible. When standing upright, they may feel like a sack of worms around the testicles or may give the impression that one testicle is larger than the other. The testicles and scrotum may experience a mild ache from larger varicoceles. Physical examination is used to make the diagnosis; grade 1 and 2 conditions are typically detected with color doppler ultrasonography.

Cost of implementing the QualityRights programme in public hospitals in Gujarat providing mental healthcare

Background & objectives: Investment in mental health is quite meagre worldwide, including in India. The costs of new interventions must be clarified to ensure the appropriate utilization of available resources. The government of Gujarat implemented QualityRights intervention at six public mental health hospitals. This study was aimed to project the costs of scaling up of the Gujarat QualityRights intervention to understand the additional resources needed for a broader implementation. Methods: Economic costs of the QualityRights intervention were calculated using an ingredients-based approach from the health systems’ perspective. Major activities within the QualityRights intervention included assessment visits, meetings, training of trainers, provision of peer support and onsite training. Results: Total costs of implementing the QualityRights intervention varied from Indian Rupees (?) 0.59 million to ? 2.59 million [1United States Dollars (US $) = ? 74.132] across six intervention sites at 2020 prices with 69-79 per cent of the cost being time cost. Scaling up the intervention to the entire State of Gujarat would require about two per cent increase in financial investment, or about 7.5 per cent increase in total cost including time costs over and above the costs of usual care for people with mental health conditions in public health facilities across the State. Interpretation & conclusions: The findings of this study suggest that human resources were the major cost contributor of the programme. Given the shortage of trained human resources in the mental health sector, appropriate planning during the scale-up phase of the QualityRights intervention is required to ensure all staff members receive the required training, and the treatment is not compromised during this training phase. As only about two per cent increase in financial cost can improve the quality of mental healthcare significantly, the State government can plan for its scale-up across the State.

Fibrolamellar hepatocellular carcinoma presenting as cholestatic jaundice: An unusual presentation of a rare disease

Fibrolamellar hepatocellular carcinoma is a rare primary hepatic tumor that usually occurs in youth. The common presenting features are vague abdominal pain, nausea, vomiting and weight loss. We present a case report of a young male who presented with cholestatic jaundice and on evaluation was diagnosed to have fibrolamellar hepatocellular carcinoma. He underwent successful surgical resection of the tumor. In young individuals presenting with unexplained cholestasis, fibrolamellar hepatocellular carcinoma should be considered.

Role of cyclin D1 in glial tumors—A retrospective and observational study

Aim: High-grade glial tumors remain as one of the most lethal malignancies. Cyclin D1 is expressed in some human malignancies and is the potential target of intervention. The present study aims to determine the relationship of cyclin D1 expression with other clinicopathological parameters. Materials and Methods: A cross-sectional study was carried out in a tertiary care center. Biopsy proven 66 cases of glial tumor patients were included in the study. The patients with incomplete clinical details were excluded from the study. Immunohistochemistry using antibodies for IDH 1 and cyclin d1 was done in all the cases. Glial tumors were reclassified according to WHO 2016 classification. Data analysis was performed using SPSS 26.0 for the windows. Result: Among 66 patients, 49 (74.3%) were males and 17 (25.7%) were females. The age of the patients ranged from 20 years to 70 years. Overall, 6.02% were of grade I Glial tumors, 22.7% were of grade II Glial tumors, 19.6% patients were of grade III Glial tumors, and 51.6% patients were of grade IV Glial tumors. Of 66 samples tested cyclin D1 was positive in 25 (37.87%) as high expressers and 7 (10.60%) were low expressers. Our study showed a significant correlation between the expression of cyclin D1 with grade and IDH mutation status, No significant correlation of cyclin D1 was noted with age or sex of the patient. Conclusion: Cyclin D1 was associated with a higher grade of the glial tumor. It can be a potential marker both for prognosis and treatment of glial tumors.

Role of Dietary Management and Physical Activity in Control of Hypertension in Rural Areas of Punjab-A Cross-sectional Study

Introduction: As reported by WHO, hypertension is the third ‘killer’ disease, accounting for one in every eight deaths worldwide. Many modifiable and non-modifiable risk factors are found to be associated with the disease. The present study aims to determine the role of dietary management and physical activity in the control of hypertension in a given population. Material and Methods: A cross-sectional study was conducted that. Study included all hypertensive patients (290) from the field practice area of a tertiary care institute. A self-constructed, pretested questionnaire was used to enquire about the socio- demographic factors and other risk factors associated with hypertension. The data was analyzed using SPSS 23 and valid conclusions were drawn by using the chi-square test. Results: Out of 290 patients, 204 (70.3%) were females and 86 (29.7%) were males. Univariate analysis identified decreased salt intake, decreased fatty food consumption, physical activity, stress management, and spiritual help as highly significant factors affecting hypertension. On multivariate analysis, physical activity, stress management and spiritual help were found to be significant. Conclusion: The study showed that physical activity, stress management and spiritual help were significantly associated with hypertension control among the elderly. Measures should be taken to create awareness about lifestyle modifications in the control of hypertension.

Health-related quality of life among people living with HIV/AIDS on highly active antiretroviral treatment: A questionnaire-based study

Introduction: The knowledge of the effect of sociodemographic and disease-related factors on health-related quality of life (HRQoL) among people living with HIV/AIDS (PLWHA) is important for planning comprehensive health-care services for them. Material and Methods: Two hundred PLWHA on antiretroviral therapy (ART) volunteered to complete a self-reported World Health Organization’s Quality of Life?HIV brief questionnaire (WHOQoL-HIV-BREF) that examines six domains each with four items (physical, psychological, level of independence, social, environmental, and spiritual) with 25 facets and additional 5 facets specific to PLWHA (symptoms of HIV, social inclusion, forgiveness, worries about the future, and death and dying). Results: Only 135 questionnaires from 73 (53.3%) men and 63 (46.7%) women (male: female – 1.14:1) aged 20–82 years(mean ± standard deviation: 42.9 ± 10.5 years) were found complete. Eighty-five (63%) individuals were aged 41–60 years, 78 (57.8%) individuals were matriculates, graduates, or postgraduates, 76 (56.3%) respondents were married, and 38 (28.1%) were widows/widowers. Staying-alone workers comprised 43 (31.8%) individuals. Overall health and HRQoL were rated satisfactory (n = 85.2%) and good/very good (n = 74.8%) by a significantly greater number of individuals (P = 0.001). Pearson’s Chi-squared test showed no statistically significant (P > ?) associations between good HRQoL and variables such as age >40 years, gender, education, marital status, duration of disease, disclosure of serostatus to family, ART for >3 years, and CD4 >200 cells/mL. Conclusion: Regular ART can result in adequate control of immunosuppression and no comorbidities in a majority of PLWHA, family and social acceptance, and financial security can result in overall good HRQoL in all six domains within the WHOQoL-HIV-BREF. The study is limited by its cross-sectional study design and small sample size.

Chondroid syringoma of an upper eyelid tumor: Unusual case report

We present the case report of a 58?year?old man with recurrent chondroid syringoma, which was histopathologically confirmed, who underwent exenteration surgery of the right eye. Furthermore, the patient was receiving postoperative radiation therapy, and presently there is no local and/or distant evidence of disease in the patient

THE ‘FEEDING BRONCHUS SIGN‘ IN CAVITARY LUNG LESIONS, ITS EVALUATION WITH COMPUTED TOMOGRAPHY AND A GUARDED OPINION REGARDING PHYSIOTHERAPY

BACKGROUND Bronchiectasis and cavitation are key features of acute and chronic pulmonary infections. Cavitary lesions may carry unfavourable prognosis with regard to complete restoration of pulmonary function in few patients. OBJECTIVES To evaluate type and site of bronchiectasis, its relation with cavity formation on computed tomography and providing an insight to sorting out subjects suited for physiotherapy. A radiological sign-“Feeding bronchus sign” has been discussed with reference to bronchiectasis, its origin, natural course and a suggestion of guarded future management and rehabilitation. METHODS Total 150 chest CT scans with presence of cavity and bronchiectasis were retrospectively reviewed and followed up for type, site of bronchiectasis, signs of active infection, site of cavity and presence of “feeding bronchus sign”. Final diagnosis was confirmed by sputum sample, acid-fast bacillus test or culture or polymerase chain reaction. RESULTS Out of 150 cases, 70 (46%) had chronic and 80 (53%) had active infection. 33 (22%) had solitary and 117 (78%) had multiple cavities. 37 (34.6 %) patients had cylindrical, 11 (7.3 %) had varicose, 27 (18%) had cystic bronchiectasis, 23 (15.3%) had cylindrical and varicose, 19 (12.6%) had cylindrical and cystic and 33 (22%) had all three types. “Feeding bronchus sign” was observed in 102 (68%) patients. Radiological evidence of disease progression was seen in 21 patients, improvement in 19 and no change in 17 on follow-up CT. CONCLUSION Patients with positive “Feeding bronchus sign” are at risk for increased disease transmission and secondary opportunistic infections. Improvement and maintenance of quality of life is ultimate goal of management. Apart from antibiotics, pulmonary rehabilitation also plays an important role in cavitary lung disease

ClinicalManifestations ofSteven'sJohnson Syndrome/Toxic Epidermal Necrolysis

BACKGROUND: Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) both reflect extreme manifestations of the same clinical entity responsible for significant, life Threatening hypersensitivity mucocutaneous reactions, caused by intraepidermal cell death resulting in epidermal sloughing and blistering; often induced by medications. The mucous membranes of the mouth, stomach, lungs,skin, and genitourinary system are all major sites of Involvement. Despite receiving effective treatment at the local and systemic levels, some survivors may have major ocular consequences that might ultimately result in blindness. It is still unknown whether or not SJS/TEN can be effectively treated locally or systemically. If you want to improve your long-term eye health, it's crucial to catch any problems early and treat them aggressively. Chronic ocular surface failure, including a lack of limbal cells and full keratinization of the ocular surface, may be detected by inspecting the eyelid edge,palpebral conjunctiva, and fornix. It is possible to lessen the danger of ocular surface failure using transplants of amniotic membrane or a cultured oralmucosal graft. AIM: The aim of this investigation is to learn more about the symptoms of SJS/TEN that emerge in the eyes. METHODOLOGY: Patients with ocular signs of SJS/TEN who sought treatment at C.U.Shah medical college and hospital, a tertiary hospital, via the OPD and IPD of skin and VD were included. Between January 2022 and May 2022, all patients had a documented ophthalmologic evaluation. RESULTS: The study had 17 participants. Ocular involvement was seen in 10 individuals, with 5 patients (50%) experiencing mild ocular indications, 2 patients (20%) experiencing moderate visual manifestations, and 3 patients (30%) experiencingsevere ocular signs. Two patients (20%) had involvement of the cornea, seven patients (70%) had involvement of the conjunctiva, and six

EFFECT OF PRONE POSITIONING WITH HFNO IN MODERATE TO SEVERE ARDS

INTRODUCTION: The WHO, broadcasted COVID 19 as a public health emergency onJANUARY 30th ,2020 and subsequently declared a pandemic on MARCH 11th2020.Acute respiratory distress syndrome (ARDS) is a major complication of COVID-19that occurs in 20-41% of patients with severe disease.The pathophysiology of ARDS andCOVID-19 lung injury share many of the same aspects of reduced lung parenchymalcompliance, vasculopathy, alveolar flooding, and gas exchange impairment arising fromdirect infectious causes and noninfectious injuries.In patients with pneumonia,HFNOallows improved mobilisation of secretions,minimises oxygen dilution,meets inspiratorydemands and improve end-expiratory lung volumes.According to the present theories,prone positioning, by reducing ventral alveolar expansion and dorsal alveolar collapse,results in ventilation that is more homogeneous.OBJECTIVE: The goal of our study is to evaluate the reduction in consumption of oxygenby using proning as an adjunct to HFNO in patients of COVID 19 admitted in ICU.METHOD: This is an observational cross sectional type of study, which includes patientswho were hemodynamically stable and required HFNO to maintain oxygenation. Allpatients were counselled for the benefits of proning. Proning was done with the help ofnursing staff. All vitals were noted before proning and all throughout proning. We keptpatients in a prone position till patients were comfortable and duration of proning wasnoted. We titrated oxygen requirement (FIO2 and flow) to target spo2 level of 93-95%.RESULT: We studied in 26 patients on HFNO with proning, we found that proning helpsin 11-50% reduction in oxygen requirement to achieve target Spo2 level.The mean value ofoxygen consumption was 20833.27 L/HR with only use of HFNO which was more than15996.92 L/HR when patients were encouraged to be prone along with the use ofHFNO.The collected data was analysed and unpaired t test was applied after which p valueof 0.0154 was obtained, which is statistically significant.CONCLUSION: Based on this study it is concluded that there is significant reduction inconsumption of oxygen by using the prone position as an adjunct to HFNO in patients ofCOVID 19.

Management of cataract in dry eye disease: Preferred practice pattern guidelines

Cataract surgery is one of the most commonly performed ophthalmic surgeries in the world. Dry eye disease (DED) is found to coexist in most patients with cataracts due to the overlapping age groups of both these conditions. Preoperative evaluation for DED is important to improve outcomes. A pre-existing DED affecting the tear film is likely to affect biometry. Moreover, special intraoperative considerations are needed in eyes with DED to reduce complications and improve postoperative outcomes. Dry eye disease (DED) is known to occur following an uneventful cataract surgery or a pre-existing DED is likely to worsen following cataract surgery as well. In these situations, despite a good visual outcome, patient dissatisfaction is common owing to the distressing DED symptoms. This review aims to summarize the preoperative, intraoperative, and postoperative considerations when performing cataract surgery in the presence of a coexisting DED.

Omega-3 fatty acids supplements for dry eye - Are they effective or ineffective?

Purpose: To evaluate effectiveness of omega?3 fatty acid supplements in relieving dry eye symptoms and signs in symptomatic visual display terminal users (VDT). Methods: A randomized controlled study was done; eyes of 470 VDT users were randomized to receive four capsules twice daily for 6 months (O3FAgroup), each containing 180 mg of eicosapentaenoic acid and 120 mg docosahexaenoic acid. The O3FA group was compared with another group (n = 480) who received four capsules of a placebo (olive oil) twice daily. Patients were evaluated at baseline, 1, 3, and 6 months, respectively. The primary outcome was improvement in omega?3 index (a measure of EPA and DHA ratio in RBC membrane). Secondary outcomes were improvement dry eye symptoms, Nelson grade on conjunctival impression cytology, Schirmer test values, tear film breakup time (TBUT), and tear film osmolarity. Means of groups (pre?treatment, 1, 3, and 6?months) were compared with repeated measure analysis of variance. Results: At baseline, 81% patients had low omega?3 index. In the O3FA group, a significant increase in omega?3 index, improvement in symptoms, reduction in tear film osmolarity, and increase in Schirmer, TBUT, and goblet cell density was observed. These changes were not significant in the placebo group. Improvement in test parameters was significantly (P < 0.001) better in patients with low omega3 index (<4%) subgroup. Conclusion: Dietary omega?3 fatty acids are effective for dry eye in VDT users; omega?3 index appears to be the predictor to identify potential dry eye patients who are likely to benefit from oral omega?3 dietary intervention

Impact of accreditation on knowledge and awareness of laboratory technicians about the aspects of laboratory quality in a tertiary care public-sector teaching hospital

Background: Laboratory diagnosis in Indian health-care setup is usually the mainstay of screening and diagnosis of diseases. Accreditation is a process of approval by establishing adherence of pre-defined quality standards to the existing system which can bring about utmost quality in service delivery by increasing accuracy and reliability and minimizing errors. Need for accreditation is ever-increasing in public sector health-care centers. Aim and Objectives: To ascertain and to quantify the impact of accreditation via training and exposure in the cadre of laboratory technicians in tertiary care public sector hospital. Materials and Methods: It was an interventional study to check competency of laboratory technicians in various domains of NABL standards, before and after training and exposure to accreditation process. It was carried out amongst MLT students and employed laboratory technicians in the clinical biochemistry department of a public sector, tertiary care, teaching hospital and lasted for 2 months. Preformed questionnaire was used. Difference between pre- and post-test results was compared with appropriate statistical analysis. Results: Marked difference was seen in the performance of study subjects before (27.6 ± 9.9) and after (56.7 ± 6.2) exposure to training and accreditation process (Max. score of 80). Average gain was 37.5%. The difference was highly significant for each domain. Domains of pre-analytical, analytical, and post-analytical procedures saw the highest difference. There was a significant difference in competence gain between student lab. techs. and employed lab. techs. Conclusion: Benefits of accreditation are immense, yet it is a voluntary process in our country. Strict adherence to already laid out standards and protocols at national level can be achieved by continuous sensitization and capacity building. Public sector laboratories need to gear up and embrace this need. The same should also be incorporated effectively in the curriculum of laboratory technician students.

Bilateral Nevus of Ota with Phakomatosis pigmentovascularis treated with 1064 nm picosecond laser: A Case Report

Nevus of Ota is an uncommon dermal melanosis in the Indian subcontinent and is rarely associated with capillary malformations, classified as type II phakomatosis pigmentovascularis (PPV). It usually presents unilaterally as mottled, slate blue, or dark bro wn macules; bilateral presentation is only seen in a few cases. A 20 - year female presented to Dermatology OPD of a tertiary hospital with bilateral nevus of Ota involving the cheeks, temples, nose, forehead, and sclera of the eyes for one year. She also ha d a port wine stain on the right arm, forearm, back, bittock, and thigh since birth without any other systemic involvement. We treated nevus of Ota with six sessions of 1064 nm picosecond laser every month at 0.8 J/cm 2 with significant improvement in the appearance of the lesions and no adverse effects. This case highlights the importance of thoroughly examining pigmented lesions for additional cutaneous findings and the potential use of a 1064 nm picosecond laser to tr eat such lesions.

Gastrointestinal tract involvement in patients with potential celiac disease beyond the small intestine: An early proof with IgA anti-tissue transglutaminase-2 antibody deposits

Background: IgA anti-tissue transglutaminase-2 antibody (anti-TG2Ab) deposits in intestinal and extraintestinal organs have been used to link the respective pathological changes in these organs with celiac disease (CeD). Aims: To know if parts of intestine other than the duodenum, such as esophagus, stomach, and colon, have any pathology related to potential CeD or have mucosal IgA anti-TG2 Ab deposits. Settings and Design: A prospective case–control study conducted from April 2018 to December 2019. Materials and Methods: Nine patients with potential CeD and 27 age- and gender-matched patients with irritable bowel syndrome were recruited as cases and controls, respectively. Mucosal biopsies were collected from esophagus, stomach, duodenum, and rectosigmoid regions, histological changes were evaluated, and IgA anti-TG2 Ab deposits were analyzed in these regions by two-color immunohistochemical staining. Statistics: Data were analyzed using statistical software Stata 14.0. Results: No distinct difference in mucosal lymphocytosis were identified between biopsies of patients with potential CeD and controls at the following sites: esophagus (11.1% vs 0%, P = 0.079), stomach (14.3% vs 7.7%, P = 0.590), and rectum (20% vs 0%, P = 0.067). Co-localized IgA anti-TG2Ab deposits were observed more in potential CeD than in controls at esophagus 22.2% (2/9) vs 0%, P = 0.012; stomach 66.7% (6/9) vs 11.5% (3/26), P < 0.001; and duodenum 66.7% (6/9) vs 0%, P < 0.001 but not at rectum 0% (0/4) vs 0% (0/25). Conclusion: Although histological changes are not distinct, a subset of subjects with potential CeD has pan-intestinal involvement other than in the duodenum.

Myeloid sarcoma presenting as nasopharyngeal mass: A rare clinicopathological scenario

Myeloid sarcoma (MS) is considered as an extramedullary manifestation of acute myeloid leukemia (AML) with or without concurrent AML. It can present at any age and any site, however, nasopharynx being an extremely rare site of manifestation. MS may precede AML by weeks, months or years, thereby necessitating an early diagnosis and timely intervention and treatment. We report a case of MS in a young female who presented with nasal obstruction and epistaxis for 3 months. The present case also highlights the significance of judicious use of immunohistochemistry panel while dealing with a hematolymphoid neoplasm devoid of expression of B-cell or T cell specific markers in head and neck region.