Melkersson Rosenthal Syndrome: A Case Report

Introduction: Melkersson-Rosenthal Syndrome (MRS) is a rare neuro-mucocutaneous condition. It mainly includes three triads as orofacial swelling, facial palsy and fissured tongue. All of the classical triad may not be seen at the same time, as symptoms may appear in different interval of time and has a recurrence. MRS is diagnosed based on oligosymptomatic when two or more clinical features are present or monosymptomatic cases when there evidence of a non-necrotising, granulomatous cheilitis in patients with isolated facial or lip edema can be noted in biopsy. Case Presentation: In this case report a 18 year old male patient all the three classic clinical characteristic features as granulomatous cheilitis, unilateral facial muscle palsy and a fissured tongue are seen. The clinical features of this rare condition along with treatment procedure are presented. Conclusion: Oral corticosteroids are the mainstay in the treatment of MRS. Intralesional triamcinolone acetonide used in oro-facial edema. In recurrent cases of MRS need second-line immunosuppressants like methotrexate and thalidomide. In refractory recurrent facial nerve palsies Surgical decompression of the facial nerve may be considered.

Small cell neuroendocrine carcinoma with primary orbital involvement – The unseen, and a review of literature

Neuroendocrine neoplasms are derived from the epithelial lineages mainly of respiratory tract, with predominant neuroendocrine differentiation. There are only a handful of documented cases of paranasal small cell neuroendocrine carcinomas (SNEC) with primary orbital involvement. Here, the authors describe a 33-year-old male patient with rapidly progressive swelling of the right lower lid with proptosis since 4 weeks. On contrast-MRI orbit, an ill-defined multilobulated mass measuring 3.6 × 3.1 cm with intense homogenous enhancement was seen in the right retrobulbar space involving the right ethmoid sinus. On incisional biopsy, a poorly differentiated mass containing numerous small round blue cells and scanty intervening stroma with prominent necrosis and apoptosis was seen. Immunohistochemistry was strongly positive for synaptophysin. He was diagnosed as a case of SNEC and received chemotherapy, with good response till date of 9 months of follow up. The authors present a literature review and describe challenges in management of a primary orbital SNEC.

Large orbital glial heterotopia- A rare entity

A 15-month-old child was brought to the ophthalmology outpatient department with his parents complaining of a large mass located on the nasal side of his right eye since birth. On examination, an irregular mass was seen to be located on the nasal side of his right orbit, obscuring the visual axis. On a contrast-enhanced computed tomography scan, a heterogenous lesion was seen to be located on the bridge of the nose and the medial aspect of the right orbit without any bony defect or communication with the brain or sinuses. In view of the possibility of developing amblyopia, the lesion was surgically removed. On histopathological examination, a diagnosis of extranasal glial heterotopia was made. To the best of our knowledge, this is the largest extranasal glial heterotopia in the orbit to be ever reported.

Sexual Experiences of Infertile Women: A Qualitative Study

It is suggested that stress related to infertility causes marriage conflicts and decreases in the frequency of sexual intercourse. Aim: This study aimed to explore the experiences of the sexuality of infertile women. Patients and Methods: A phenomenological design was used in this study. We conducted face-to-face, semistructured, in-depth interviews with 11 infertile women. The interviews were audio-recorded, and a thematic approach was used to assess the data. Results: The average age of the women was 33.05 ± 3.40 years, and their age of first sexual intercourse was 23.0 ± 2.8 years and all of them are legally married. The durations of experiencing the problem of infertility were as follows; 3-5 years in 33%, 6-10 years in 27%, and 11 years and above in 38%. According to interpretative phenomenological analysis, two main themes emerge. Two main themes were determined: Perception of Sexuality and Sexual Problems. The results show that infertile women have a higher risk for sexual dysfunction than fertile women. Conclusion: These findings suggest that the diagnosis of infertility is an important factor in assessing the differences in the sexual satisfaction of women. In infertility counseling, health professionals must explain the gender differences. Also, infertile couples must encourage to share each other's feelings and this may help couples to cope with the communication problems they may experience.

Evaluation of PD-L1 and PD-1 expression in aggressive eyelid sebaceous gland carcinoma and its clinical significance

Purpose: Eyelid sebaceous gland carcinoma (SGC) is an aggressive but rare malignancy of ocular region. Over-expression of PD-L1 and PD-1 has been demonstrated in a variety of solid tumors including conjunctival melanoma. PD-L1 is an immunoinhibitory molecule that suppresses the effective T cells response against tumor antigen leading to the progression of tumors. Inhibitors of the interaction of PD-L1 and PD-1 are associated with good clinical response various carcinomas. The prognostic value of the PD-1/PD-L1 axis in SGC remains unexplored. The purpose of this study was to evaluate expressions of PD-1 and its ligand PD-L1 in SGC and correlate its expression with clinicopathological features and patients survival. Methods: The immunohistochemical expression of PD-L1 and PD-1 was evaluated in 30 SGC cases. Results: PD-L1 immunopositivity was detected in 41.9% of the SGC cases. PD-1 expression in tumor infiltrative lymphocytes (TILs) was observed in 53.3% samples. Tumor PD-L1 positivity, PD-1 expression in TILs and tumor size (>10 mm) was associated with reduced disease-free survival. On multivariate analysis only tumor size (>10 mm) and a combined positivity of PD-L1 in tumor cells and PD-1 in TILs with an odds ratio of 5.212 (95% confidence interval 1.449-18.737) continued to be signifi�cantly associated with SGC recurrence. Conclusion: PD-L1 is overexpressed in 50% of SGC cases. The combined tumor PD-L1 positivity and TILs showing PD-1 expression within the same SGC patient's samples predict high-risk SGC, suggesting that the up-regulation of PD-L1 in tumor cells and PD-1 positivity within the same SGC patient may aggravate tumor recurrence.

Vertical rectus transposition procedures for lateral rectus palsy: A systematic review

Multiple transposition procedures have been described for management of lateral rectus palsy. However, relative effect and indications of each procedure are unclear. This systematic review was planned to evaluate functional and anatomical outcomes of vertical rectus transposition (VRT) surgery in patients with lateral rectus palsy. We searched databases in English language, namely, MEDLINE, PubMed Central, EMBASE, Google Scholar, Scopus, and Index Copernicus without any date restrictions in electronic searches, using the search words 'vertical rectus transposition for lateral rectus palsy,” “vertical rectus transposition for abducens palsy,” “superior rectus transposition,” “inferior rectus transposition,” and “Hummelsheim procedure.” References of the selected publications were also searched to find any relevant studies. We searched for studies that provided data on single VRT and double VRT surgeries for lateral rectus palsies. Three authors independently assessed the related studies gathered from electronic and manual searches. We found 27 studies which were relevant to the review question. As there were no randomized control trials (RCTs) available related to our study question, nonrandomized studies were used to arrive at summarization of outcomes of different transposition procedures. There is a need for prospective RCTs to investigate the different types of transposition procedures for lateral rectus palsy.

Modification Of Gums By Periodate Oxidation: A Natural Cross-Linker

Scientists throughout the world are in search of novel modified biopolymer to fabricate smart drug delivery systems based on hydrogel formulations using several cross-linkers like glutaraldehyde, glyoxal, epichlorhydrin, adipic acid dihydrazide, carbodiimide, genipin, etc. Agents that are fused into the polymeric structure like isocyanates, glutaraldehyde, polyepoxides, etc., and are extremely toxic in nature. In addition, these are susceptible to percolate out into the body on biodegradation of polymeric structure. As an alternative to these toxic cross-linking agents, the periodate-Schiff base staining technique is widely being used for cross-linking in biology and biochemistry. The mechanism of this cross-linking technique is based on the reaction in-between the Schiff reagent and the aldehydes produced via the periodate oxidation. During the past few decades, several researchers have already been studied on the natural gums and also, developed their dialdehyde derivatives via the periodate oxidation technique. These periodate oxidized gums are being used to cross-link gelatin, other proteins and chitosan to develop various smart systems for drug delivery, tissue engineering, wound dressing, edible films, etc. The current review presents a comprehensive discussion of the available reported literature on the periodate oxidation of various gums and their use as natural cross-linker.

Active-fluidics-based torsional phacoemulsification in diabetic eyes: A prospective interventional study

Purpose: To compare the outcomes of active-fluidics based torsional phacoemulsification in diabetics and nondiabetics using a balanced tip. Methods: Two hundred and forty-eight patients undergoing senile cataract surgery using torsional phacoemulsification on an active-fluidics-based platform from December 2016 to August 2017 were included in this prospective, nonrandomized, interventional cohort study; of the 248 patients, 54 were controlled diabetics and 194 were nondiabetics. Intraoperative parameters such as cumulative dissipated energy (CDE), total ultrasound time, torsion usage time, torsion amplitude, aspiration time, and fluid usage were documented and compared. Endothelial cell loss (ECL) and central corneal thickness (CCT) were evaluated at 1 month postoperatively. Results: Diabetics and nondiabetics did not differ in CDE, total ultrasound time, torsion amplitude, aspiration time, fluid usage, endothelial cell count, and CCT. ECL on Day 1 (10.2 ± 8.0%) and Day 30 (11.05 ± 8.3%) were significantly higher in diabetics (P = 0.025 and P = 0.045, respectively). There was an increase in CCT on Day 1 (P = 0.018), which settled by Day 30. Grade 4 cataracts in diabetics had significantly higher CCT at Day 1 (P = 0.032) and Day 30 (P = 0.007). In the diabetic subgroup, Grades 3 and 4 cataracts required lower CDE (P < 0.001) and Grade 4 cataracts showed higher ECL than others till 1 month of follow-up (P < 0.05). Conclusion: Intraoperative and postoperative parameters after torsional phacoemulsification are comparable in diabetics and nondiabetics. Endothelial changes and pachymetry may be related to the grade of cataract in diabetics.

Diagnostic value of serum adenosine deaminase in Type 2 diabetic patients

Background: Adenosine deaminase (ADA) is suggested to modulate the bioactivity of insulin, but its clinical significance in Type 2 diabetes mellitus (DM) is not yet established. The present study was undertaken to evaluate serum ADA activity and serum uric acid levels in patients of Type 2 DM. Aim: To evaluate the serum ADA level and to correlate ADA levels with Blood Glucose, Glycated Hemoglobin (HbA1c) levels in Type-2 DM patients. Material and Method: It is a case control study. The subjects in this study were divided into 3 groups. Group I consisted of 50 normal healthy individuals who served as controls with no history of DM. Group II consisted of 50 patients of Type 2 DM both males & females in the age group of 40-65 years on oral hypoglycemic drugs with HbA1c <7%. Group III consisted of 50 patients of Type 2 DM both males & females in the age group of 40-65 years on oral hypoglycemic drugs with HbA1c >7 %. Serum levels of fasting blood sugar, HbA1c, ADA and uric acid were estimated in all the subjects. Results: FBS, HbA1c, ADA and serum uric acid levels were found to be increased in the patients of Type 2 DM as compared with controls. Conclusion: It is concluded that there is an increase in serum ADA levels with increase in HbA1c levels. Serum uric acid levels increased with moderately increasing levels of HbA1c <7% and then decreased with further increasing levels of HbA1c >7% (a bell-shaped relation).

Perceived difficulties and complications in learners of phacoemulsification: A principal component analysis model

Purpose: To evaluate the difficulty perceived of each step of phacoemulsification and analyze the factors affecting them. Methods: Overall, 12 trainee residents were allotted 10 cases of phacoemulsification of eyes with senile cataract, under a single observer, and the steps of each surgery were rated from very easy to very difficult with a questionnaire. The completion rates of steps and complications of each surgery were noted. Principal component analysis of the responses to the difficulty level questionnaire was conducted to obtain factors resulting in the perceived difficulty. Results: The lowest difficulty scores were for initial step of incision creation (1.63 � 0.84), followed by intraocular lens insertion (2.51 � 0.8). The most difficult step was divide/chop of the nucleus (3.74 � 0.97) followed by phacoemulsification (3.32 � 0.82). Highest completion rates were seen for the initial steps of the surgery and the lowest for divide/chop. We identified two major patterns of difficulty among the trainees � one for steps involving high amount of binocularity and the other, for steps involving high precision of hand control. The rate of complication of our study was within acceptable range. Conclusion: Although trainees have practiced phacoemulsification steps on simulation, real-life situation may bring in unprecedented level of difficulty and challenges, which may be documented and used for targeted improvement of surgical skills. Stereopsis and hand control training should form a major part of training modules of cataract surgery both on simulation and real-life scenarios.

Does the use of induction chemotherapy in oral cavity cancer compromise subsequent loco‑regional treatment delivery: Results from a matched pair analysis.

BACKGROUND: Neoadjuvant chemotherapy is being increasingly used in patients with unresectable oral cavity cancers to make them resectable. However, its impact on locoregional treatment delivery in such setting remains poorly studied. AIMS: To evaluate the impact of neoadjuvant chemotherapy on delivery of further locoregional treatment. SETTINGS AND DESIGN: Mono institutional retrospective audit of patients with oral cavity squamous cell cancers treated with neoadjuvant triplet chemotherapy in India. MATERIALS AND METHODS: Patients receiving neoadjuvant chemotherapy (n = 14) from May 2012 to April 2014 were matched 1:2 to patients undergoing upfront surgery (n = 28) based on age (>60 or 60 and less), gender (male or female) and subsite site (tongue and floor of mouth or buccoalveolar complex). Data regarding factors related to the delivery of locoregional treatment and toxicities were compiled. STATISTICAL ANALYSIS: Descriptive analysis in the form of median (range) for continuous variables and frequencies for categorical variables. RESULTS: Patients undergoing neoadjuvant chemotherapy required more extensive resections and had greater operative time (460 vs. 415 min, P < 0.001). A greater incidence of locoregional wound complications was seen as a consequence (57.1% vs. 14.3%, P, 0.01). However, toxicities during radiotherapy were not substantially different between the two groups and compliance to radiation was also similar. Total package time of 100 days or less, was maintained in 90% of patients in both groups. CONCLUSIONS: Delivery of neoadjuvant chemotherapy does not impair the ability to deliver locoregional treatment.

Outbreak of Pneumocystis jirovecii pneumonia in renal transplant recipients on prophylaxis: Our observation and experience.

Pneumocystis jirovecii is a life‑threatening opportunistic pathogen affecting immunocompromised hosts, especially renal transplant recipients. This study reports an outbreak of seven such cases, both inpatients and outpatients, occurring in our hospital over a period of 4 months (January–April 2013). All patients were male with a median age of 38 years (range, 28–58 years); the median period between transplantation and diagnosis was 39.5 months (range, 11–123 months). One patient succumbed to the infection. Two were breakthrough cases, developing the infection while on prophylaxis, highlighting the need to view prophylaxis in light of the immunosuppression and clinical picture of such patients.

Recurrent Scar Endometriosis in A Young Lady of 23 Years.

A young lady of 23 years was admitted in the Gynaecology & Obstetrics department of the Community Based Medical College Hospital, Bangladesh with sensation of irregular fixed mass in left side of lower anterior abdominal wall in and around her previous scar for 01 year and periodic pain in that mass for 8 months during menstruation. Some times she felt colicky pain in lower and umbilical region, not related with menstruation. This lady was married for 6 years and para – 01 (still birth) and delivery was done by lower uterine caesarean section 4½ years back, and developed such mass for a few months after lower uterine caesarean section. This mass was excised 3½ years back. On the basis of history , clinical findings, ultra sonongrphic finding and histopathological report, this case was diagnosed as scar endometriosis. She was also getting post operatively synthetic androgen for 6 months (400 mg daily). She again developed that mass 01 year after operation. Now she is almost free from pelvic pain by using synthetic androgen (Denazol) and is advised for pregnancy with assisted by reproductive technology. All current therapies offer relief but cannot assure cure of recurrent scar endometriosis. Even after definitive surgery, endometriosis may recur. Definitive surgical treatment followed by long term oestrogen therapy yields better results. However the future treatment options should greatly improved upon what is offered now.

Anesthesia for emergency cesarean section.

Caesarean Section is one of the most common of all surgical procedures. Common indications for caesarean section may include foetal distress, Cephalopelvic disproportion and failure of labour to progress. Both regional and general anesthesia may be employed for caesarean section. Each is relatively safe and they have their own advantages and disadvantages. Actual decision to adopt one technique over another depends on maternal and foetal status and skill and ability of the anesthesiologist to tackle the situation with the aim of patient and baby safely. Among these, many of the cases come to the hospital as emergency basis. The Anesthesiologists have to face the challenge in providing anesthesia for emergency caesarean section, being the last member in the perinatal team. The challenge faces the risks in involvement of maternal changes in pregnancy, presence of foetal distress and various anesthetic complications arising in perioperative period. Still now anesthetic mishaps are considered as the sixth most frequent cause of maternal mortality. The use of regional Anesthesia reduced the number of deaths at about 80% but deaths involving general anesthesia has not decreased and the incidence is 17 times more than the regional anesthesia. Most of the deaths or complications are related to the airway management (also failed intubation). Better skill and knowledge in physiology, pharmacology and use of modern Anesthetic technique is essential to face the problems.

Chromoblastomycosis.

A case of a 45 years male patient with irregular warty growths over the right leg of 35 years duration is reported. The diagnosis was confirmed mycologically and histopathologically. Isolate was identified as Fonsecaea pedrosoi.

Iodine deficiency disorders among school children of Dakshin Dinajpur District, West Bengal.

Iodine deficiency disorders (IDD) are major public health problems in India, including West Bengal. Existing programme to control IDD needs to be continuously monitored through recommended methods and indicators. Thus we undertook the study to assess the prevalence of goiter, status of urinary iodine excretion (UIE) level and to estimate iodine content of salts at the household level in Dakshin Dinajpur district, West Bengal. We conducted a community-based, cross-sectional study in 2004; among 2250 school children, aged 8-10 years. The '30 cluster' sampling methodology and indicators for assessment of IDD, as recommended by the joint WHO/UNICEF/ICCIDD consultation, were used for the study. Goitre was assessed by standard palpation technique, UIE was analyzed by wet digestion method and salt samples were tested by spot iodine testing kit. Of the 2250 children, 419 (18.6%) had goitre (95% CI = 17.0 - 20.2%). Total goitre rate (TGR) was not significantly different in respect of gender, age and religion. Visible goitre rate was 2.5%. Median urinary iodine excretion level was 16 mcg/dL (normal: > or = 10 mcg/dl.) and 16.5% children had value less than 5 mcg/dL. Only 67.4% of the salt samples tested had adequate iodine content of > or = 15 ppm, with significant difference between Hindus and Muslims (chi2 = 12.68, d.f. = 1, p < 0.01). TGR of 18.6% indicate the district is still endemic for IDD, but median urinary iodine within normal range reflects no current iodine deficiency. The district is in the transition phase from iodine-deficient to iodine-sufficient. Measures are to be sustained for successful transition towards elimination.

Pulmonary involvement in chronic arsenic poisoning from drinking contaminated ground-water.

OBJECTIVES: Chronic arsenic poisoning, due to ingestion of contaminated ground-water, is a major public health problem in West Bengal. It causes multiorgan damage. The present study attempts to objectively investigate the pulmonary involvement by examining the lung function. The nature of lung changes was also evaluated. MATERIAL AND METHODS: One hundred and seven subjects with (cases) and 52 subjects without (controls) chronic arsenic poisoning were examined by spirometry. Forced expiratory volume-I second (FEVI), forced vital capacity (FVC) and peak expiratory flow rate (PEFR) were measured. Bronchoalveolar lavage (BAL) was performed in five cases with and five cases without pulmonary involvement. RESULTS: Thirty three (30.8%) cases and four (7.6%) controls (p<0.01) had respiratory involvement. The pattern of involvement in cases was: obstructive- 20(68.9%) (including three (10%) with bronchiectasis), restrictive- 1(3.5%), mixed- 8(27.6%), malignancy- 4(12.1%) (adenocarcinoma-I, squamous cell- 2, undifferentiated- I). FEVI (69.7+/-25.9 [n=105] vs 83.7+/-15.19 [n=51], p=0.0005), FVC (77.4+/-22.7 [n=105] vs 85.6+/-18.23 [n=51], p=0.025), FEVI/FVC (73.6+/-13.38 [n=105] vs 79.1+/-18.65 [n=52], p=0.007) and PEFR (53.9+/-21.52 [n= 103] vs 67.3+/-18.36 [n=51], p=0.0002) (percent of predicted) were all reduced more in cases compared to controls. Worsening of these parameters correlated with increasing degree of arsenic toxicity. Markers of inflammation (macrophage, lactate dehydrogenase, nitric oxide) were apparently more in the BAL fluid of those with lung involvement than in those without, though the arsenic content did not differ significantly. CONCLUSION: Chronic arsenic poisoning causes pulmonary involvement, predominantly obstructive, the degree of which worsens with increasing degree of arsenic toxicity. Inflammation, rather than direct toxicity, appears to be the underlying mechanism.