Simple limbal epithelial transplantation (SLET): Review of indications, surgical technique, mechanism, outcomes, limitations, and impact

Simple limbal epithelial transplantation (SLET) is an innovative limbal stem cell transplantation technique that has gained increasing popularity over the last few years. Different groups from across the world have published the clinical results of SLET in large case series with varying types and severities of limbal stem cell deficiency (LSCD). This review attempts to place all the available knowledge on SLET together in one place for the benefit of not only cornea specialists and trainees but also for residents and general ophthalmologists. It follows a balanced approach of blending evidence with experience by providing an objective analysis of published results along with helpful insights from subject experts, starting from preoperative considerations including the role of newer imaging modalities to the technical aspects of the surgery itself and the management of possible complications. Original data and novel insights on allogeneic SLET for bilateral LSCD are included in the review to address the few remaining lacunae in the existing literature on this topic. This review intends to inform, educate, and empower all aspiring and practicing SLET surgeons to optimize their clinical outcomes and to have maximal positive impact on the lives of the individuals affected by unilateral or bilateral chronic LSCD.

Current practice in handling and reporting needle biopsies: A hospital-based survey

Context: Core-needle biopsy (CNB) is a minimally invasive screening and diagnostic tool which provides intact tissue fragments for histopathological examination. Aims: This study was conducted to review the current practices of handling and reporting CNBs performed for core-needle biopsies from four organ systems which are frequently encountered in our institution. These include breast, prostate, soft tissues, and lymph nodes. Settings and Design: This was a retrospective study conducted at a tertiary care hospital. Materials and Methods: CNB reports of breast, prostate, soft tissue, and lymph nodes were accessed and categorized based on the site of biopsy, number, and average length of the cores. The CNB reports were categorized into diagnostic or nondiagnostic. In case of diagnosis of malignancy, reports were recorded as structured or nonstructured reports. Statistical Analysis Used: Fisher's exact test and Chi-square tests were applied to check the significance of the results obtained on comparing the number of cores and size of cores with the outcome of report. Results: Out of 16,300 surgical pathology specimens received, 400 were CNBs comprising breast (n = 211), prostate (n = 108), soft tissue (n = 50), and lymph node (n = 31). Majority of the CNBs had 2–5 cores and the size of the core was ≥0.5 cm, which accounted for most of the reports which were diagnostic. There was a lack of clinical and radiological detail in many of the cases. Out of the malignant cases diagnosed, structured reports were given in 30% of breast, 79.3% of prostate, 41.7% soft tissue, and 60% of lymph node needle biopsies. Conclusions: The audit helped to identify areas of improvement in CNB services.

Qualitative defects with normal sperm counts in a patient attending infertility clinic

Background: Sperm morphology is an important qualitative parameter in semen analysis. Aim: To assess qualitative defects in the semen with normal sperm counts. Setting and Design: This was a prospective and descriptive study done in a tertiary care center. Materials and Methods: Seventy-five semen samples with normal sperm counts were evaluated. Qualitative defects of sperms on Papanicolaou-stained slides were assessed. The defects were noted as follows: head (tapering head, large head, small head, round head, bifid head), middle piece (bent neck, broad middle piece, excess residual cytoplasm), and tail (coiled tail). Results: All cases showed the qualitative defects in spite of the normal counts. The defects found in head – pointed/tapering head (1%–20%), round head (1%–7%), large head (1%–3%) and others (0%–2%); in middle piece – bent neck (1%–8%), excess cytoplasm (1%–3%) or broad middle piece (1%–12%); and in tail – coiled tail (1%–5%). Conclusions: Qualitative defects are often seen even in cases with normal sperm counts.

Comparative Evaluation of Angiotensin-Converting Enzyme Inhibitors for their Beneficial Effects in Patients with Ischemic LV Systolic Dysfunction and Undergoing Coronary-Artery Bypass Surgery.

We compared three angiotensin-converting enzyme (ACE) inhibitors, captopril, perindopril, and ramipril, in the presented prospective study for their effectiveness in patients having left ventricular (LV) systolic dysfunction and undergoing coronaryartery bypass grafting (CABG). We enrolled 27 patients in captopril, 43 patients in perindopril, and 70 patients in ramipril group. There was about 25%–36% rise in LVEF after 3 and 6 months of ACE inhibitor administration in all three groups. The reduction in LV diameters did not differ significantly amongst the three groups. There was a significant decrease (p < 0.05) in LV end-diastolic diameter from baseline levels in captopril and perindopril groups after 3 months that got increased after 6 months but remained below pretreatment levels in both the groups. In ramipril group, there was no much change in this parameter from baseline levels at 3 and 6 months of treatment. After 6 months of treatment, the percent reduction in LV end-systolic diameter was also sustained in perindopril-treated patients. The percent reduction was greater in the perindopril group (3 and 6 months: 7.39 ± 5.94 and 7.73 ± 3.43, respectively) as compared to that observed in captopril group (3 and 6 months: 5.67 ± 1.05 and 2.52 ± 3.11, respectively) and ramipril group (3 and 6 months: 7.30 ± 2.75 and 4.93 ± 3.22, respectively). Mitral-valve regurgitation was greatly reduced in the captopril group at 3 as well 6 months of ACE inhibitor administration. However, the percent reduction from baseline levels was not statistically significant amongst the three groups. The percent improvement in functional status was significantly greater in the ramipril treatment group (36.46 ± 3.14) after 6 months of treatment as compared to that of captopril (6.67 ± 10.64) and perindopril (4.17 ± 2.73) group. In conclusion, our data show equal beneficial effects with all three ACE inhibitors under investigation in CABG patients with LV systolic dysfunction, with marginal superiority for perindopril.

Health Status of Elderly Persons in Rural Area of India.

Introduction : The population in developing countries is increasing day by day due to the development of medical science and availability of medical facilities at their door steps. This results in an increasing numbers of elderly persons which contributes to 7% of India’s population. Elderly are vulnerable to long term diseases of insidious onset such as cardiovascular illness, CVA, cancers, diabetes, musculoskeletal and mental illnesses. Hence the study was conducted to assessing the health status and morbidity pattern among the rural elderly. Methods: A cross sectional study was conducted in 6 Primary Health Centers (PHCs) in India among elderly persons who were 60 years and above .One PHC which was selected by random sampling method among six PHCs. 20% of all elderly persons from all the villages in selected PHC by systematic random sampling which formed the study sample (494).All these peoples were examined clinically & necessary information was collected from them. Results: Commonest morbidity observed among the elderly people was depression (31.4 %) followed by musculoskeletal disorder (25.5 %), hypertension (24.1 %), gastrointestinal problems (11.5 %), diabetes mellitus (5.9 %), & neurological problems (4.7 %). Conclusion: This study has highlighted that the elderly suffers from multiple morbidities, which they often attribute to ageing. It requires the strengthening of geriatric health care services in accordance with the common existing problems in the community.

Bronchoscopic management of benign bronchial stenosis by electrocautery and balloon dilatation.

Benign bronchial stenosis is managed by surgical or bronchoscopic methods. Although surgical approach is definitive, it is technically demanding and is costlier than bronchoscopic treatment. Here, we report the case of a 27-year-old female patient with symptomatic benign bronchial stenosis of the left main bronchus. The stenosis was dilated successfully through a fibreoptic bronchoscope by electrocautery followed by balloon bronchoplasty and application of mitomycin-C. On follow up, there was no evidence of re-stenosis.

Bronchoscopic management of bronchopleural fistula.

In recent years successful bronchoscopic management of bronchopleural fistulas (BPFs) by locating its site and then blocking the leaking segment with any of the several agents available has gained recognition. It is now considered as an alternate mode of management of BPF. Here we present a case of non-resolving pneumothorax that was managed successfully using bronchoscopic glue (cyanoacrylate glue) instillation.

Predictors for antenatal services and pregnancy outcome in a rural area: A prospective study in Wardha district, India.

Background :Antenatal care is essential to reduce morbidity and mortality among newborn babies and pregnant women. Aims: To study the pattern of utilization of antenatal services and to find out the potential predictors, their distributions and their association with antenatal care utilization and pregnancy outcomes. Settings and Design :A prospective longitudinal study was conducted in Deoli, a rural teaching area of a medical college of Wardha district, Maharashtra state. Materials and Methods : Medical social workers contacted all the registered 305 pregnant women in 1 month. A total of 274 women were included in the study. The response rate was 89.83%. Statistical Analysis Used : Percentages, rate ratio. Results : Mean age at marriage was 19.8±3.6 years, and the average age at first pregnancy was 21.6± 4.5 years. Of the 274 pregnant women, 156 (56.9%) were pregnant for the first time (gravida 1), and the remaining 118 (43.1%) pregnant women, gravida 2 and above, had an average of 2.1 living sons and 1.9 living daughters. Only 92 (33.6%) women had undergone the minimum recommended antenatal checkup during their current pregnancy, and 188 (68.6%) women had institutional deliveries. A large proportion of women in Deoli do not receive proper health care during pregnancy and childbirth. Conclusion : In Deoli, antenatal services, in spite of being essential to the care of pregnant women, are being poorly delivered.

Rhodotorula mucilaginosa as a cause of persistent femoral nonunion.

We present a case of postoperative infection which presented as nonunion fracture femur in a 30-year-old man due to Rhodotorula mucilaginosa. This is the first report of Rhodotorula infection in a patient with fracture nonunion. The patient underwent repeated surgical debridement and received intensive antibiotic therapy before the diagnosis was made. The diagnosis could have been made earlier if the fungal etiology had been suspected earlier. Early suspicion and diagnosis of infection with atypical yeasts could be under-reported because of difficulties in accurate diagnosis and a tendency of attributing isolates to specimen contamination.

Antimicrobial resistance in invasive and colonising Streptococcus pneumoniae in North India.

The present study was done to detect the antibiotic resistance in S. pneumoniae. One hundred twenty S. pneumoniae isolates from clinical specimens and 50 from nasopharyngeal sites were subjected to antimicrobial susceptibility testing by Kirby Bauer disk diffusion method and minimum inhibitory concentration (MIC) determination for penicillin and cefotaxime non-susceptible isolates. A total of 22 isolates (18.3%) from clinical sites and eight (16%) from nasopharyngeal sites showed decreased susceptibility to penicillin by oxacillin disk diffusion test. MICs of 26 of these resistant strains ranged from 0.12-1 microg/mL (intermediate resistance) by broth dilution and E test. Only four isolates, two from sputum and two from nasopharyngeal swabs, showed MIC of 2 microg/mL (complete resistance). However, MIC of two cefotaxime resistant isolates (by disk diffusion) was in the susceptible range (0.5 microg/mL). Highest antimicrobial resistance was seen to cotrimoxazole (55.2%) and tetracycline (61.2%). Antimicrobial resistance to cotrimoxazole and tetracycline was much more in clinical isolates than colonizing isolates. Multi-drug resistant phenotype was detected in 76.9% (20 of 26) of isolates that were intermediately sensitive to penicillin and 50% (2 of 4) of penicillin resistant isolates (co-resistant to tetracycline and cotrimoxazole). Routine screening for antibiotic susceptibility is recommended for clinical isolates of pneumococci. Strains with reduced susceptibility to penicillin should be subjected to MIC determination to detect relative resistance or true resistance as such strains are associated with increased virulence.The choice of antibiotics should be guided by the prevalence of local resistance patterns of pneumococci.

Edible vaccines: current status and future.

Edible vaccines hold great promise as a cost-effective, easy-to-administer, easy-to-store, fail-safe and socioculturally readily acceptable vaccine delivery system, especially for the poor developing countries. It involves introduction of selected desired genes into plants and then inducing these altered plants to manufacture the encoded proteins. Introduced as a concept about a decade ago, it has become a reality today. A variety of delivery systems have been developed. Initially thought to be useful only for preventing infectious diseases, it has also found application in prevention of autoimmune diseases, birth control, cancer therapy, etc. Edible vaccines are currently being developed for a number of human and animal diseases. There is growing acceptance of transgenic crops in both industrial and developing countries. Resistance to genetically modified foods may affect the future of edible vaccines. They have passed the major hurdles in the path of an emerging vaccine technology. Various technical obstacles, regulatory and non-scientific challenges, though all seem surmountable, need to be overcome. This review attempts to discuss the current status and future of this new preventive modality.

Simple and economical method for speciation and resistotyping of clinically significant coagulase negative staphylococci.

An attempt was made to speciate 102 clinically significant isolates of coagulase negative staphylococci (CoNS) by a practical scheme adapted from various references. This scheme utilizes slide and tube coagulase test, urease test ornithine decarboxylase, novobiocin susceptibility and aerobic acid from mannose for assigning species group. Inclusion of one or two additional tests in a species group could identify the isolates to species level. Ninety eight (97%) isolates were conveniently identified as S. epidermidis (41%), S. saprophyticus (16.6%), S. haemolyticus (14.7%), S. hominis (14.7%), S. lugdunensis (4.9%), S. schleiferi (1.9%) and S. capitis (1.9%). Only four isolates were not identified to the species level, two of which were probably S. capitis subspecies ureolyticus / S. warneri / S. simulans . Antibiotic susceptibility testing showed maximum resistance to ampicillin (89%) followed by cefotaxime (59%) with no resistance to vancomycin. The increasing recognition of pathogenic potential of CoNS and emergence of drug resistance amongst them denotes the need to adopt simple laboratory procedures to identify and understand the diversity of staphylococci isolated from clinical material.

Hepatoprotective activity of Hemidesmus indicus R. br. in rats.

Treatment of rats with paracetamol and CCl4 produced a significant increase in the levels of serum glutamate pyruvate transaminase (SGPT), serum glutamate oxaloacetate transaminase (SGOT), alkaline phosphatase (ALP), total and direct bilirubin. Rats pretreated with methanolic extract of roots of H. indicus (100-500 mg/kg body weight, po) exhibited rise in the levels of these enzymes but it was significantly less as compared to those treated with paracetamol or CCl4 alone. The results of methanolic extract of H. indicus were comparable with the standard hepatoprotective agent silymarin (100 mg/kg). Maximum hepatoprotective effect was found to be at the dose of 250 mg/kg body weight in case of CCl4 induced hepatic damage while 500 mg/kg body weight in case of paracetamol induced hepatic damage. The results suggest that methanolic extract of H. indicus roots possesses a potential antihepatotoxic activity.

Recurrent lymphocytic hypophysitis in a woman 27 years after subtotal adrenalectomy for hypercortisolism possibly of autoimmune origin.

Lymphocytic hypophysitis commonly occurs in females in peripartum period but several unusual presentations have been reported. Here we report a rare case of recurrent lymphocytic hypophysitis in a woman who had subtotal adrenalectomy for hypercortisolism 27 years back. Polyglandular autoimmune endocrinopathy with an uncommon combination of Cushing's syndrome and recurrent hypophysitis is a strong possibility in this case. Treatment with steroids has been found to have beneficial effect.

Phenotypic characteristics of clinical isolates of Klebsiella pneumoniae & evaluation of available phenotypic techniques for detection of extended spectrum beta-lactamases.

BACKGROUND & OBJECTIVES: Identifying organisms that harbour extended spectrum beta lactamases (ESBLs) is a major challenge for a diagnostic clinical microbiology laboratory. Wide variety of ESBLs produced and lack of a sensitive phenotypic method for their detection make the detection of ESBLs difficult and is responsible for under-recognition. The present study was undertaken to evaluate phenotypic characteristics, initial screening tests and established confirmatory phenotypic methods for detection of ESBLs Klebsiella pneumoniae isolates prevalent in a hospital in north India. METHODS: One hundred, non-repeat clinical isolates of K. pneumoniae collected over a period of six months were included in the study. Susceptibilities of the isolates to 20 different antimicrobial agents were determined. Agar dilution and broth dilution methods were used to determine minimum inhibitory concentrations (MICs) of ceftazidime (CAZ) and cefotaxime (CTX). CAZ and CTX were used with and without clavulanic acid to detect ESBL harbouring isolates. Using agar dilution and broth dilution, MIC reduction of two and three doubling dilutions were evaluated as a criterion for ESBL harbouring isolates. Standard double disk synergy test (DDST) with disks placed at 30 mm and modified DDST with disks placed at 16 mm center-to-center distance, using at least two different third generation cephalosporins and combined disk method were also performed to detect ESBL harbouring isolates. RESULTS: Multi-drug resistance (resistance to three or more antimicrobials of different classes) was found among 94 per cent of the isolates. Pooling the results of all the three confirmatory techniques MIC reduction of >3 doubling dilutions using broth dilution method (using CTX and CAZ), combined disk method [(using CTX, ceftriaxone [(CRO), CAZ and aztreonam)] and standard DDST (using CTX, CRO, CAZ and aztreonam), revealed as many as 87 per cent of the isolates as ESBL producers. CTX had greater sensitivity in identifying isolates that harboured ESBLs. Modified DDST using CTX was as sensitive method as broth dilution method and combined disk method in detecting ESBL harbouring isolates. MIC reduction technique using agar dilution method and standard DDST had lowest overall sensitivity in detecting ESBLs. INTERPRETATION & CONCLUSION: Modified DDST using at least two different third generation cephalosporins was considered to be the best technique for detection of ESBL producing K. pneumoniae at our hospital. MIC reduction test with >2 doubling dilution reduction in MICs was found to be a better criterion than the presently recommended >3 doubling dilution reduction. For screening of potential ESBL producers, MIC determination using agar dilution was as good as that using broth dilution method. However, while performing MIC reduction test agar dilution method was found highly unreliable for detection of ESBL harbouring isolates.

Septic arthritis due to Arcanobacterium haemolyticum.

Diphtheroids or "coryneform" bacilli are usually considered to be nonpathogenic "normal flora" of human skin and mucous membranes. Because bacterial cultures are frequently contaminated with these organisms the correct diagnosis and treatment may be delayed by the failure to recognize serious infections caused by them. Few confirmed cases of orthopaedic infections due to Arcanobacterium haemolyticum infection have been reported, partly because of inadequate identification of this bacterium. We report a case of septic arthritis due to A. haemolyticum.

Spotted dermopathy in a diabetic patient due to insulin allergy.

A rare case of diabetic patient who developed multiple cutaneous hyperpigmented spots following bovine isophane (NPH) insulin injection is described here.