Epidermoid cysts of the orofacial region: A clinico-pathological study of 13 cases with review of literature

Background: Epidermoid cysts (ECs) are uncommon benign cystic lesions derived from the germinative epithelium. Head and neck ECs constitute only 7% of all ECs whereas only 1.6% are seen intraorally. The floor of the mouth is the commonest intraoral site whereas tongue, lips, buccal mucosa, and jaws are less commonly involved intraoral sites. To date, very few large case series of ECs of head and neck have been published. To the best of our knowledge, this is the third-largest case series of 11 intraoral ECs along with 2 extra-oral cases in the pre-auricular region. Aims: To highlight the typical and atypical features of ECs in the common as well as rare sites and draw attention to its consideration as a differential diagnosis for head and neck masses. Settings and Design: Archival data of 13 histopathological cases identified as ECs were analyzed from the Department of Oral Pathology at a tertiary dental hospital and college in New Delhi from 2007 to 2020. Materials and Methods: The demographic, clinical, radiographic, histopathological features, and treatment modalities were recorded and analyzed. Statistical Analysis Used: Appropriate statistical tests were used. Results: The study found strong male predilection in the ratio of 10:3 with an average age of presentation as 28 years. The pre-auricular region and floor of the mouth were the common sites involved followed by buccal mucosa, lips, and jaws. All patients presented with slowly growing swelling with dysphagia, dyspnea, and dysphonia seen in larger cysts on the floor of the mouth. Microscopically, all cases were lined with stratified squamous epithelium filled with laminated layers of keratin. Two cases showed the presence of melanin. One case showed recurrence even after complete surgical excision. Conclusion: ECs, though a rare entity, should be considered in differential diagnosis for head and neck masses and require close follow-up due to their potential for malignant transformation.

Is Follow-up Co-Morbidity Assessment via Laboratory Investigations in Older High Energy Trauma Patients Justified? - A Prospective-Retrospective Study

@#Introduction: The objective of the current study was to test our hypothesis that older patients sustaining high energy trauma need to be evaluated for their comorbidities similar to geriatric patients sustaining low energy trauma. Materials and methods: This study was a retrospectiveprospective analysis of 173 patients of more than 50 years of age enrolled between November 2017 and December 2018. Herewith, we have compared retrospectively collected laboratory investigations of 124 fragility fracture patients with prospectively collected laboratory investigations of 49 patients with high energy trauma. The laboratory investigations, including the liver function tests, renal function tests, indices of calcium metabolism, serum electrolytes, complete blood counts, and bone mineral density (BMD) scores. Results: Both groups were similar to each other as far as baseline demographic characteristics were concerned. The proportion of female patients and patients with nonosteoporotic range BMD (T-score >-2.5) was significantly higher in the high-energy fracture group (P value <0.05). Hypoalbuminemia (<3.4gm/dl) 17.3%, abnormalities sodium (<135mmol/L or >148mmol/L) 23.2%, Anaemia (<10g/dl) 12.7%, Hypercalcemia (>10.4mg/dl) 16.3%, Vitamin D deficiency (<20ng/ml) 17.3% are the common laboratory abnormality found in study population. No statistically significant difference was found among the two groups in terms of laboratory investigation abnormalities. Conclusion: The laboratory investigation abnormality in an older patient with a clinical fracture is independent of the mechanism of injury. The results of the current study emphasise the need for a comprehensive laboratory workup in older patients with either high- energy fractures or fragility fractures.

Outcomes in Nonagenarians with Hip Fractures Treated Conservatively and Surgically

@#Introduction: We aimed to assess the clinical outcomes in nonagenarians following a hip fracture. We also further investigated the factors that influence these outcomes, such as method of treatment (operative versus conservative), comorbidities, and pre-morbid function. Materials and methods: We studied 65 nonagenarians that were identifiable from our hospital hip fracture database. We reviewed various parameters of these patients admitted after sustaining a hip fracture (neck of femur or intertrochanteric) and investigated how these parameters affected patient outcomes. The main outcomes studied were: inpatient morbidity, and mortality at one year. Results: Inpatient morbidity was more likely in patients with an ASA grade of 3 to 5. Urinary tract infection was the most common medical complication. The 1-year mortality was 15.4% and was significantly influenced by advancing age. Surgically managed patients had a 1-year mortality rate (14.3%) slightly less than non-operative patients (17.4%). Post injury mobility was significantly better in those who received operative treatment with 63% of surgical cases regaining ambulatory status versus 7% of conservatively managed patients. Conclusions: We presented the outcomes of hip fractures in an extreme age group in the population. In nonagenarians with hip fractures surgery was associated with a 1-year mortality rate of 14.3% which is comparable to the general hip fracture population and less than the mortality rate of conservatively managed patients (17.4%). The primary advantage of surgery would be that two-thirds of patients return to ambulatory status. This information is useful to counsel patients and their families especially since the elderly are often more fearful of surgical intervention.

Protocol for developing a surveillance system for surgical site infections

Purpose: Healthcare-associated infections (HCAIs/ HAIs) are the most common adverse occurrences during health care delivery. Across the globe, millions of patients are affected by HAIs annually, with a higher burden and impact in developing nations. a major lacuna in planning preventing protocols is the absence of National Surveillance Systems in most low-middle income countries, which also prevents allocation of resources to the high-priority areas. Among all the HAIs, there is a huge global burden of SSIs, in terms of morbidity, prolonged hospital stays, increased antimicrobial treatment as well as attributable mortality. Method: This manuscript details the process of establishment of an SSI surveillance protocol at a level-1 trauma centre in North India. Result and Conclusion: Surveillance is an essential tool to reduce this burden. It is also an important primary step in recognizing problems and priorities, and it plays a crucial role in identifying risk factors for SSI and to be able to target modifiable risk factors. Therefore, it is imperative to establish reliable systems for surveillance of HAIs, to regularly estimate the actual burden of HAIs, and to use these data for developing indigenous preventive measures, tailored to the country's priorities.

Sonication of antibiotic loaded cement spacers: A valuable technique for detection of infection persistence in two-stage revision for infected joint arthroplasty

We evaluated the diagnostic utility of sonication of antibiotic loaded cement spacers comparing with periprosthetic tissue cultures for the detection of persisting infection in 14 patients undergoing staged procedures. Sonication improved microbial detection of intraoperative cultures from 14.2% to 28.5% (P = 0.481). Routine sonication of spacers is recommended.

Pathogen burden & associated antibiogram of Pseudomonas spp. in a tertiary care hospital of India

Antimicrobial resistance particularly in Gram-negative bacilli is an increasing problem worldwide. Pseudomonas spp. is one the most common Gram-negative bacteria associated with nosocomial infections and therefore, its trend of antimicrobial resistance needs to be studied. The aim of this study was to evaluate the rate of antimicrobial resistance and changes in resistance pattern over a period of five years (2012-2016) in Pseudomonas spp. isolated from trauma patients attending a tertiary care hospital in north India. During the study, a total of 2444 Pseudomonas spp. were isolated from the various clinical sample. The most common species isolated was P. aeruginosa (2331, 95%). The highest level of resistance was observed against levofloxacin (1678, 69%) and the lowest level of resistance was observed against tobramycin (1254, 51%). Irrational and inappropriate use of antibiotics was found to be responsible for multidrug resistance in Pseudomonas spp. Hence, there is an urgent need to emphasize strict antibiotic policy to minimize the misuse of antimicrobials.

Phenotypic & genotypic profile of antimicrobial resistance in Pseudomonas species in hospitalized patients

Background & objectives: Nosocomial infections caused by multidrug-resistant, Pseudomonas species have become a major clinical and public health concern. The aim of this study was to characterize phenotypic and genotypic profile of antimicrobial resistance (AMR) in Pseudomonas spp. isolated from hospitalized patients. Methods: A total of 126 consecutive, non-duplicate isolates of Pseudomonas spp. isolated from various clinical samples were included in the study over a period of two years. Identification and antimicrobial sensitivity was performed using automated culture system according to the Clinical and Laboratory Standards Institute (CLSI) recommendations. Phenotypic detection of extended-spectrum ?-lactamases (ESBLs), Amp-C ?-lactamase (AmpC) and metallo-?-lactamases (MBLs) were done by various combinations of disc-diffusion and E-test methods, followed by polymerase chain reaction-based detection of ?-lactamase-encoding genes. Results: Among 126 clinical isolates, 121 (96.1%) isolates were identified as Pseudomonas aeruginosa. Most of the isolates were recovered from pus sample, 35 (27.8%) followed by urine, 25 (19.84%); endotracheal aspirate, 24 (19.04%); blood, 14 (11.11%) and sputum, four (3.17%). The highest rate of resistance was against ticarcillin-clavulanic acid, 113 (89.7%) followed by meropenem, 92 (72.5%) and ceftazidime, 91 (72.3%). Overall, ESBLs, AmpC and carbapenemase production was detected in 109 (96.4%), 64 (50.8%) and 105 (94.6%) isolates by phenotypic methods. The most prevalent ESBL gene was blaTEMin 72 (57.1%) and the least prevalent was blaSHVin 19 (15.1%) isolates. AmpC gene was seen less compared to ESBL gene. The most prevalent carbapenemases gene was blaNDM-141 (46.06%) followed by blaVIM and blaOXA-1. Interpretation & conclusions: Our findings suggested that a high rate of ESBLs and carbapenemases production was observed in Pseudomonas spp. Therefore, phenotypic and genotypic detection of AMR needs to be combined for better characterization of resistance patterns in Pseudomonas spp.

Prosthetic joint infection: A major threat to successful total joint arthroplasty

Total joint arthroplasty (TJA) is one of the most common and reliable orthopaedic procedures that has significantly improved the quality of life of patients with degenerative joint diseases. Following the increase in the ageing population, availability of trained orthopaedic surgeons and advances in implantation procedures, demand for TJA both globally and in India is significantly increasing. Though TJA is one of the most cost-successful orthopaedic procedures, prosthetic joint infection (PJI) is one of the major complications of joint arthroplasty. Accurate diagnosis of PJI is challenging. Since total hip and knee arthroplasties comprises the majority of TJAs, this review focuses on the current understanding of incidence, risk factors, pathogenesis, causative microorganisms, diagnosis, treatment and prevention of PJI related to these two procedures.

Upper eyelid levator-recession and anterior lamella repositioning through the grey-line: Avoiding a skin-crease incision

Purpose: This study aims to report a case series of upper eyelid cicatricial margin entropion with retraction, corrected through a grey-line approach only. We remind readers of the grey-line approach to levator recession (LR) and lamellar repositioning surgery. Methods: A retrospective review of clinic notes and photographs of patients who underwent grey-line split (GLS), LR, release of orbital septum, recession of levator, advancement of posterior lamella and anterior lamellar repositioning without a skin crease incision, from December 2015 to December 2016. Indications for surgery included mild-to-moderate cicatricial margin upper eyelid entropion, tarsal curling, and meibomian gland inversion. Patients requiring spacer interposition to lengthen the posterior lamella were excluded from the study. Parameters of the study included lid margin position, lid height, ocular surface health and symptom improvement. Results: Eleven eyelids of eight patients were included in the study, and underwent the procedure described. Lid margin position measured as the marginal reflex distance lowered (improved) in 72.7% of patients. Lid margin eversion was achieved in all eyes (100%). Corneal punctate epithelial erosions markedly improved, being present in 72.7% of patients preoperatively, and only 9.1% of patients postoperatively. Eight of eleven eyes showed symptomatic improvement, with six (54.5%) being completely asymptomatic and two achieving partial relief. An added observation was a pretarsal show asymmetry in some patients which improved in 36.4% of surgeries postoperatively. Conclusion: Upper eyelid LR with GLS and anterior lamella repositioning can all be performed through the plane of the split, avoiding a skin incision. Normal lid margin apposition was achieved in all eyes with 91% demonstrating a clear cornea and 72% having symptomatic improvement.

Prosthetic joint infection due to Lysobacter thermophilus diagnosed by 16S rRNA gene sequencing.

We report the first case of prosthetic joint infection caused by Lysobacter thermophilus which was identified by 16S rRNA gene sequencing. Removal of prosthesis followed by antibiotic treatment resulted in good clinical outcome. This case illustrates the use of molecular diagnostics to detect uncommon organisms in suspected prosthetic infections.

Increasing access to cataract surgery in a rural area--a support strategy.

The objectives of the study were to elicit the reasons for not undergoing cataract surgery from those having cataract, aged 50 years and above, in a village community and, develop, implement and assess a support strategy for getting cataract surgery done. The leading reasons identified were monetary constraints (18.8%), transport difficulty (17.4%), lack of awareness about cataract in the eyes (17.4%) and lack of escort (14.5%). Based on the identified reasons, patients were transported in groups to a government eye hospital for free surgery after completion of required pre operative formalities at the village health center itself. Out of 65 eligible individuals, 66.2% underwent surgery. The success of the approach was evident by perceived improvement in vision in 88.4% operated patients, occurrence of only few minor complications and a satisfactory hospital experience being reported by all.

Qualitative study of wild polio cases in high risk districts of Uttar Pradesh, India.

BACKGROUND: India has implemented a polio eradication strategy which includes national immunization days and house-to-house visits. While there has been a reduction in wild polio cases, a few districts in some states continue to harbour the virus. We did a qualitative survey in certain districts of western Uttar Pradesh to determine the reasons for continued occurrence of wild polio cases. METHODS: Five districts of western Uttar Pradesh were selected where 10 confirmed cases of polio were studied in their local settings using qualitative tools. RESULTS: All 10 cases were below 5 years of age and belonged to the poor socioeconomic group. Except 3, all had received some doses of oral polio vaccine before the onset of illness. The majority of parents had a 'feeling of guilt' and blamed the 'bad destiny of their child' for the disease. There was a strong belief that the 'polio vaccine is mixed with substances which can cause infertility' and that it was 'used for a particular community'. CONCLUSION: Prevailing misconceptions and adverse attitudes to the polio vaccine need to be tackled urgently and sensitively to make the programme successful.

Health care seeking pattern of tuberculosis patients attending an urban TB clinic in Delhi.

The study of pattern of health care seeking of tuberculosis patients is important for identification of factors which might influence delayed reporting of tuberculosis cases, especially the open pulmonary cases. Consecutive 301 pulmonary TB patients, belonging to any of the categories under RNTCP, diagnosed at New Delhi Tuberculosis Centre or its sub-centres over a six-month period were assessed for health care seeking pattern. "Delay" was defined as the time over 3 weeks that a case took to report to the area TB facility. 43.2% patients reported to the TB health facility on their own and others were referred by government hospitals (34.9%) and general practitioners (21.9%). Median delay over 3 weeks was 2.69 weeks for all three categories combined, with a significantly higher delay (3.41 weeks) for retreatment cases as compared to new cases (2.13 weeks). No significant differences were observed in health seeking delay in relation to sex, income, literacy status and source of referral and sputum status. Extensive health education activities can reduce this period of delay in health seeking and result in reduction of transmission of tuberculosis to healthy members of the family and community.

p24 antigen screening to reduce the risk of HIV transmission by seronegative bone allograft donors.

BACKGROUND: During the last decade, more than 2000 bone allografts harvested from 888 donors and processed by the Queensland Bone Bank have been transplanted in over 1500 patients in Australia and New Zealand. A strict protocol to eliminate HIV transmission by fresh frozen allografts is followed; and not a single case of HIV transmission has been reported. METHODS: All donors were screened and strict donor exclusion criteria were used. All donor blood samples were subjected to double testing including antibody to HIV-1, HIV-2 and HTLV-1 and p24 antigen. The allografts negative for these tests were subjected to processing, including removal of extraneous tissue, pulsatile lavage to remove marrow elements, and immersion in 97% alcohol for 20 minutes. Allografts were subjected to 25 cGy irradiation before transplantation. RESULTS: Allografts were retrieved from a total of 950 donors and 51 were discarded after screening for contamination by organisms other than HIV-1. Eleven donors negative for HIV-1 antibodies tested positive for p24 antigen and were discarded. Allografts from donors testing negative for both the tests (n = 888) were irradiated and used for transplantation. CONCLUSIONS: Routine p24 antigen testing and irradiation of allograft should be mandatory for bone banks, especially those freezing fresh allografts. p24 antigen testing is inexpensive, rapid and easy. Certain guidelines must be followed to avoid misleading results of p24 testing.

Role of computed tomography in patients with hemoptysis and a normal chest skiagram.

Thirty patients of hemoptysis with a normal skiagram chest were evaluated by computed tomography. Majority of the patients were between 21 to 50 years of age. Seventy percent had mild hemoptysis while 30 percent had moderate hemoptysis. Computed tomography provided diagnostic information in 16 patients (53%). The various aetiologies were bronchiectasis (20%), tuberculosis (20%), pneumonia (6.7%), bronchial carcinoid in one case and allergic bronchopulmonary aspergillosis in one case. Computed tomography may play a role in screening patients who present with hemoptysis with normal chest radiographs.

The impact of new technologies on vaccines.

Vast changes are taking place in vaccinology consequent to the introduction of new technologies. Amongst the vaccines included in the Expanded Programme of Immunization (EPI), the pertussis vaccine has been replaced by acellular purified fractions devoid of side-effects. Non-pathogenic but immunogenic mutants of tetanus and diptheria toxins are likely to replace the toxoids. An effective vaccine against hepatitis B prepared by recombinant technology is in large-scale use. Conjugated vaccines against Haemophilus influenzae b, S. pneumococcus and meningococcus are now available, as also vaccines against mumps, rubella and measles. Combination vaccines have been devised to limit the number of injections. Vaccine delivery systems have been developed to deliver multiple doses of the vaccine at a single contact point. A genetically-engineered oral vaccine for typhoid imparts better and longer duration of immunity. Oral vaccines for cholera and other enteric infections are under clinical trials. The nose as a route for immunization is showing promise for mucosal immunity and for anti-inflammatory experimental vaccines against multiple sclerosis and insulin-dependent diabetes mellitus. The range of vaccines has expanded to include pathogens resident in the body such as Helicobacter pylori (duodenal ulcer), S. mutans (dental caries), and human papilloma virus (carcinoma of the cervix). An important progress is the recognition that DNA alone can constitute the vaccines, inducing both humoral and cell-mediated immune responses. A large number of DNA vaccines have been made and shown interesting results in experimental animals. Live recombinant vaccines against rabies and rinderpest have proven to be highly effective for controlling these infections in the field, and those for AIDS are under clinical trial. Potent adjuvants have added to the efficacy of the vaccines. New technologies have emerged to 'humanize' mouse monoclonals by genetic engineering and express these efficiently in plants. These recombinant antibodies are opening out an era of highly specific and safe therapeutic interventions. Human recombinant antibodies would be invaluable for treating patients with terminal tetanus and rabies. Antibodies are already in use for treatment of cancer, rheumatoid arthritis and allergies. An advantage of preformed antibodies directed at a defined target and given in adequate amounts is the certainty of efficacy in every recipient, in contrast to vaccines, where the quality and quantum of immune response varies from individual to individual.