A Case of Lepromatous Leprosy with Laryngeal Involvement Presenting as Dysphonia

Involvement of larynx is a uncommon manifestation but could be the first time when the patient may be reporting to a specialist. This is the case report of a 65-year-old man who presented with dysphonia, was evaluated and was diagnosed as lepromatous leprosy with laryngeal involvement. On clinical examination the patient was found to have signs of leprosy – leonine face, nodular involvement of ears, madarosis, oedema of hands and feet, trophic ulcer on right foot. Bilateral greater auricular nerves were found to be enlarged. Video laryngoscopy revealed pale edematous epiglottis, arytenoid and aryepiglottic folds, with nodules on epiglottis. Biopsy from aryepiglottic fold and skin both was done. The diagnosis of lepromatous leprosy was confirmed with histopathology of biopsy from both skin and epiglottic fold. MRI imaging of the neck with contrast showed diffuse hyperintensity in the glottic-supraglottic larynx with asymmetry in the aryepiglottic fold and vocal cord. This experience shows that clinical suspicion is most critical element in reaching the diagnosis of leprosy

Surgical management of large hepatocellular carcinoma: the first single-center study from western india / Manejo cirúrgico de grandes carcinomas hepatocelulares: primeiro estudo de um único centro da índia ocidental

ABSTRACT Background: Majority of patients with large size HCC (>10 cm) are not offered surgery as per Barcelona Clinic Liver Cancer (BCLC) criteria and hence, their outcomes are not well studied, especially from India, owing to a lower incidence. Aim: To analyze outcomes of surgery for large HCCs. Methods: This retrospective observational study included all patients who underwent surgery for large HCC from January 2007 to December 2017. The entire perioperative and follow up data was collected and analyzed. Results: Nineteen patients were included. Ten were non-cirrhotic; 16 were BCLC grade A; one BCLC grade B; and two were BCLC C. Two cirrhotic and three non-cirrhotic underwent preoperative sequential trans-arterial chemoembolization and portal vein embolization. Right hepatectomy was the most commonly done procedure. The postoperative 30-day mortality rate was 5% (1/19). Wound infection and postoperative ascites was seen in seven patients each. Postoperative liver failure was seen in five. Two cirrhotic and two non-cirrhotic patients had postoperative bile leak. The hospital stay was 11.9±5.4 days (median 12 days). Vascular invasion was present in four cirrhotic and five non-cirrhotic patients. The median follow-up was 32 months. Five patients died in the follow-up period. Seven had recurrence and median recurrence free survival was 18 months. The cumulative recurrence free survival was 88% and 54%, whereas the cumulative overall survival was 94% and 73% at one and three years respectively. Both were better in non-cirrhotic; however, the difference was not statistically significant. The recurrence free survival was better in patients without vascular invasion and the difference was statistically significant (p=0.011). Conclusion: Large HCC is not a contraindication for surgery. Vascular invasion if present, adversely affects survival. Proper case selection can provide the most favorable survival with minimal morbidity.

RESUMO Racional: A maioria dos pacientes com CHC de grande porte (>10 cm) não tem indicação cirúrgica conforme os critérios do Barcelona Clinic Liver Cancer (BCLC) e, portanto, seus resultados não são bem estudados, principalmente na Índia, devido a uma menor incidência. Objetivo: Analisar os resultados da cirurgia para HCCs de grande porte. Métodos: Este estudo observacional retrospectivo incluiu todos os pacientes submetidos à cirurgia para grandes CHC de janeiro de 2007 a dezembro de 2017. Todos os dados perioperatórios e de acompanhamento foram coletados e analisados. Resultados: Dezenove pacientes foram incluídos. Dez não eram cirróticos; 16 eram BCLC grau A; um BCLC grau B; e dois eram BCLC C. Dois cirróticos e três não-cirróticos foram submetidos à quimioembolização transarterial sequencial pré-operatória e embolização da veia porta. Hepatectomia direita foi o procedimento mais comumente realizado. A taxa de mortalidade pós-operatória em 30 dias foi de 5% (1/19). Infecção da ferida e ascite pós-operatória foram observadas em sete pacientes cada. Insuficiência hepática pós-operatória foi observada em cinco. Dois pacientes cirróticos e dois não cirróticos apresentaram vazamento de bile no pós-operatório. O tempo de internação foi de 11,9±5,4 dias (mediana de 12 dias). A invasão vascular estava presente em quatro pacientes cirróticos e cinco não cirróticos. O acompanhamento médio foi de 32 meses. Cinco pacientes morreram no período de acompanhamento. Sete tiveram recorrência e sobrevida mediana livre de recorrência foi de 18 meses. A sobrevida livre de recorrência cumulativa foi de 88% e 54%, enquanto a sobrevida global cumulativa foi de 94% e 73% em um e três anos, respectivamente. Ambos eram melhores em não-cirróticos; no entanto, a diferença não foi estatisticamente significante. A sobrevida livre de recidiva foi melhor nos pacientes sem invasão vascular e a diferença foi estatisticamente significante (p=0,011). Conclusão: CHC grande não é contraindicação para cirurgia. Invasão vascular, se presente, afeta adversamente a sobrevida. Seleção adequada de casos pode fornecer sobrevida mais favorável com morbidade mínima.

Parental perception of quality of life in children following cardiac surgery

Background: Congenital heart disease (CHD) is one of the major causes of mortality in the pediatric population of both the developing and developed countries. Along with medical and surgical treatment, access to quality care is equally essential in children operated with CHD. This study aims at assessing how the parents perceive quality of life in the child post-operatively and the impact on family.Methods: About 185 parents of children operated for CHD were interviewed using Pediatric Quality of Life Inventory' 3.0 Cardiac, Paediatric Quality of Life Inventory' (PedsQL') Family Impact Module scale and Participation Measure using International Classification of Functioning, Disability and Health-Child Youth by World Health Organization-2007 (ICF-CY) after three months of surgery.Results: CHD was found to be more common among males (57.8%) with commonest surgery being ventricular septal defect (36.8%) followed by tetralogy of fallot and others. Overall 44.8% parents perceived their child had problem following surgery, cognition being the most affected domain. Problems in communication were perceived by 47.6% parents and were worried about the future. Using ICF-CY, 55.1% perceived complains of mild difficulty in mobility and moderate difficulty in self-care and schooling for the child.Conclusions: The overall quality of life of children operated for congenital heart disease was perceived as not affected by parents except for cognitive problems. Parental worry and communication were the most affected domains. As far as schooling and self-care is concerned there was moderate difficulty. There is need for parental counselling and rehabilitation to function for children operated for cardiac surgery post operatively.

Isolation And Antimicrobial Susceptibility Pattern Of Staphylococcus Aureus.

Introduction- Staphylococcus aureus is one of the principal human pathogens that colonizes healthy individuals as well as causes severe infections in hospitalized patients. They have differential ability to spread and cause outbreaks in hospitals. The study was done to isolate S.aureus from various clinical samples and to know their antibiogram. Methodology- The study included a total of 312 Staphylococcus aureus strains isolated from various clinical specimens. The specimens received were processed further for identification by standard microbiological procedures like direct microscopic examination, culture and various standard identification methods. Antimicrobial susceptibility testing was done by Kirby-Bauer disc diffusion method on Mueller-Hinton agar as per CLSI guidelines. Result- A total of 312 isolates of S. aureus were obtained from various clinical samples. Male to female ratio was 1.6:1. Infection rate was more in age group 46-60 years. Staphylococcus aureus isolates were more commonly obtained from surgery department (38.78%) followed by orthopedics. All the strains were 100% sensitive to Vancomycin, Netilmicin, Linezolid and Teicoplanin. Higher resistance was noted against Penicillin(94.87%), Trimethoprim/Sulfamethoxazole(72.44%).Lower resistance was noted against Nitrofurantoin(13.33%). Conclusion- The determination of the anti-microbial susceptibility is also crucial for an optimal therapy, for epidemiological purposes and for infection control measures.

Antiviral activity of crude extracts of Eugenia jambolana Lam. against highly pathogenic avian influenza (H5N1) virus.

Crude extracts of leaves and bark of E. jambolana were tested for antiviral activity against highly pathogenic avian influenza virus (H5N1) by CPE reduction assay in three different layouts to elucidate virucidal, post-exposure and pre-exposure antiviral activity of the extracts. The cold and hot aqueous extracts of bark and hot aqueous extract of leaves of E. jambolana showed significant virucidal activity (100% inhibition) which was further confirmed in virus yield reduction assay (~98 to 99% reduction) and by egg based in ovo assay. The selective index (CC50/EC50) of hot aqueous extract (248) and cold aqueous extract (43.5) of bark of E. jambolana showed their antiviral potential against H5N1 virus. The significant virucidal activity of leaves and bark of E. jambolana merits further investigation as it may provide alternative antiviral agent for managing avian influenza infections in poultry farms and potential avian-human transmission.

Immediate effect of nostril breathing on memory performance.

The self-control study on thirty normal subjects of both genders (mean age 25.83±3.41 years) were taken in a self control study group and were tested for three types of Nostril breathing practices and Breath Awareness (BA) effects. Namely verbal recall performance of numerical data such as Digit Span Forward (DSF) and Digit Span Backward (DSB) as well associate learning memory function using Wechsler Memory Scale. The interventions included Right Nostril Breathing (RNB), Left Nostril Breathing (LNB), Alternate Nostril Breathing (ANB) and Breathe Awareness for duration of 30 minutes daily, four consecutive days. The Repeated Measure ANOVA analysis revealed a significant increase in both DSF and DSB recall performance due to RNB at P<0.001 level and increased DSB score due to ANB at P<0.014 level with a non- significant increase due to LNB suggests that the RNB facilitates both DSF and DBF recall performance. However, the LNB effect on left hemisphere helps to restore the memory function of right hemisphere. This study concludes that the RNB enhances numerical data retrieval mostly as a result of left brain activation.

Yogic exercises and health – A psycho-neuro immunological approach.

Relaxation potential of yogic exercises seems to play a vital role in establishing psycho-physical health in reversing the psycho-immunology of emotions under stress based on breath and body awareness. However, mechanism of yogic exercises for restoring health and fitness components operating through psycho-neuro-immunological pathways is unknown. Therefore, a hybrid model of human information processing-psychoneuroendocrine (HIP-PNE) network has been proposed to reveal the importance of yogic information processing. This study focuses on two major pathways of information processing involving cortical and hypothalamo-pituitary-adrenal axis (HP A) interactions with a deep reach molecular action on cellular, neuro-humoral and immune system in reversing stress mediated diseases. Further, the proposed HIP-PNE model has ample of experimental potential for objective evaluation of yogic view of health and fitness.

Musculoaponeurotic fibromatosis of both bones of forearm.

Desmoplastic fibroma is a rare primary tumour of bone. When it does occur, the sites of predilection are the long bones. The following is a case report of desmoplastic fibroma involving both bones of forearm in a 12 year old boy with a review of literature.

Cross reactivity of cephalosporins with penicillin.

Cross antigenicity of cephalosporins with penicillin has been studied experimentally and also by using serum from penicillin sensitive individuals. Definite hypersensitivity reaction was observed in all the animals sensitised with cephalosporins and challenged with penicillin except in rats. Cephalosporins could elicit reaction in tissues sensitised passively with serum obtained from penicillin sensitive individuals.

Effect of histamine on wound healing.

Using incision, excision and dead space wound models in rats, a study was conducted on the effect of histamine on wound healing. Exogenous histamine given either ip or locally was without any effect. Semicarbazide as (histamine synthesis inhibitor) suppressed healing process (breaking strength of skin incision wound), decreased breaking strength and hydroxyproline content of granulation tissue and delay in period of epithelization. On the other hand compound 48/80 (a promoter of histamine forming capacity) was found to promote wound healing. Exogenous histamine (topical) reversed the anti-healing effect of semicarbazide on incision and excision wounds.

Effects of antihistamines on wound healing.

Role of antihistamines (H1 and H2 blockers) in wound healing by utilizing incision and dead space wound models in albino rats was investigated. H1 blockers (mepyramine and promethazine) were found to decrease breaking strength of 10 day old dermal incision wounds and collagen content (as hydroxyproline) and breaking strength of granulation tissue harvested over tubular implant. On the other hand H2 blockers (Cimetidine and ranitidine) did not alter the above parameters. The findings that H1 blockers suppress healing implicate H1 receptors in alleged prohealing effect of histamine, and suggest clinical evaluation of these agents for suppression of overhealing states like keloid, adhesions and strictures.

A simple method to quantify maturation of wound collagen.

While investigating the effect of NSAIDs and Zn(II) (NSAIDs)2 complexes on healing of dead space wounds we found that both NSAIDs and Zn(II) (NSAIDs)2 reduced collagen content to a comparable extent yet only NSAIDs reduced breaking strength (BS) of wounds. Since collagen content and maturation are the two important determinants of BS it was obvious that only NSAIDs reduced maturation. A simple method to assess the extent of maturation in available collagen is being reported in the present study. While all NSAIDs significantly reduced the maturation of collagen, Zn(II) (NSAIDs)2 complexes per se did not affect the maturation of collagen of 10-day old. Though, chronologically, granulation tissues obtained from both the treated groups were 10-day old, maturation-wise the age of NSAIDs and Zn(II) (NSAIDs)2 treated granulation was 6 and 12 days respectively.

Comparative evaluation of tolmetin & tolmetin-zinc on wound-repair & inflammation.

In view of the reported healing-suppressant activity of some NSAIDs and absence of this adverse effect in their zinc-complexes, tolmetin (Tol), a recently introduced NSAID and its zinc-complex (Tol-Zn) were compared for their wound healing and antiinflammatory profiles in male albino rats. Tolmetin-zinc (Tol-Zn) significantly reversed (P less than 0.01) the suppressant effect of Tol on gain in breaking strength of skin incisions and dead space wounds (breaking strength, g: for control, Tol and Tol-Zn were: 313 +/- 7, 250 +/- 11, 294 +/- 16 in skin wounds; 244 +/- 7, 137 +/- 18, 195 +/- 16 in dead space wounds). Tol-Zn shared the significant (P less than 0.001) suppressant effect of Tol on granuloma formation (granuloma weight, mg: control - 69 +/- 3, Tol - 36 +/- 3.03, Tol-Zn - 37 +/- 2.75) and its collagen content (total hydroxyproline per tissue, microgram: control - 1955 +/- 55, Tol - 1400 +/- 200, Tol-Zn - 1410 +/- 150). Rat paw edema induced by carrageenin was significantly (P less than 0.001) reduced by Tol as well as Tol-Zn. In the chronic model both the agents suppressed significantly (P less than 0.001) granuloma formation by 50 per cent. Zinc sulphate by itself reduced the rat paw edema by 39 per cent (P less than 0.02) and did not affect the other parameters. Zinc-complex appears to be an improved version of tolmetin as an antiinflammatory agent with no adverse effect on the healing process. Tolmetin-zinc promotes gain in breaking strength, not by increasing the collagen content, but by favouring better maturation of available collagen at the wound site.

Biochemical mechanisms and effects of Mimosa pudica (Linn) on experimental urolithiasis in rats.

Urolithiasis, following implantation of Zn discs in urinary bladder (foreign body insertion technique), was examined in albino rats of either sex. Marked variation was observed between sex, regarding the formation of bladder stones. Ethylene glycol (1%) mixed in drinking water for 4 weeks, was unable to augment Zn disc-induced stone deposition. Chemical nature of stones was identified as of magnesium ammonium phosphate type. Neither urinary pH nor infection in the urinary bladder/tract affected chemical nature and quantity of stone formed. There was no significant influence of electrolytes or metabolic products on the uroliths. No correlation could be drawn between the quality and quantity of uroliths formed and the urinary electrolytes concentration. M. Pudica was not effective in either preventing stone deposition or dissolving preformed stones.

Effects of procoagulants on wound healing.

As blood coagulation is a prelude for wound healing, a systemic haemocoagulant (Botropase) and local procoagulants (thrombin and fibrin) were evaluated on physical (wound breaking strength, wound half-closure time and period of epithelization), biochemical (granuloma-hydroxyproline and hexosamine) and histological attributes of healing wounds in albino rats. Botropase prompted all phases of tissue repair. Thrombin delayed wound contraction whereas fibrin had no discernable action. The findings that procoagulants modify healing process has bearing on their surgical use.

Multiple cold abscesses in a borderline lepromatous patient on multidrug therapy.

A 25-year-old male patient was diagnosed as a case of borderline lepromatous (BL) type of leprosy in erythema nodosum leprosum type reaction. He was put on multidrug treatment. He took regular treatment. Approximately a year after the beginning of the treatment he developed multiple cold abscesses and later tuberculosis of the left hip joint. He was given antitubercular treatment with 4 drugs and the abscesses were treated surgically. He showed good response. This unusual case and the role of intermittent rifampicin is discussed.

Pretreatment with phenobarbitone modifies suppressant effect of cyclosporine on wound healing.

Cyclosporine has been reported to suppress the tensile strength of healing incision wound. Prednisolone, an inducer of hepatic microsomal enzymes, abolished the tensile strength suppressant effect of cyclosporine. Cyclosporine is metabolized by the hepatic cytochrome P-450 enzymes. Induction of microsomal enzymes with phenobarbitone was evaluated for its effect upon the wound healing suppressant effect of cyclosporine. Pretreatment of male rats with phenobarbitone (75 mg/kg/day, ip) for 3 days resulted in alleviating the tensile strength suppressant effect of cyclosporine (5 mg/kg/day, po for 10 days). Phenobarbitone, per se, did not affect the tensile strength. That phenobarbitone prevents cyclosporine induced nephrotoxicity without affecting the humoral immunosuppressant action of cyclosporine has recently been reported. The possibility of modulating microsomal enzymes with phenobarbitone offers another approach in preventing cyclosporine-associated toxicities during immunosuppression.

Estradiol induced vaginal cornification in spayed rats: a model to study hepatic microsomal enzyme induction.

Utilizing vaginal cornification as a response for bioassay, a study was conducted to observe the variation in the median cornification dose (cED50) of estradiol, a hepatic-first-pass candidate, given either ip or sc in spayed rats, with or without enzyme induction by rifampin. Comparisons within and between the groups showed that after enzyme induction cED50 was increased fourfold and cED50 ip/cED50 sc ratio was doubled. The findings clearly demonstrate that this animal model faithfully reflects alterations in hepatic enzyme activity and could serve as an alternate for conventional hexobarbitone sleeping time test to study enzyme induction.