An Unusual Case of Recurrent Cutaneous Carcinomas Over Extragenital Multicentric Pigmented Bowen's Disease.

Bowen's disease is a slowly progressive squamous cell carcinoma (SSC) in situ with high potential for malignant transformation. In this case, we describe a patient with multicentric Bowen's disease for the past 26 years, developing growths over his left buttock. The patient had a previous history of growth developing over his right thigh, and was diagnosed with metatypical basal cell carcinoma (BCC). The points that make this case noteworthy are recurrent cutaneous carcinomas over the multicentric generalized occurrence of in situ SCC of extragenital type, the rarity of the site, and the nature of its morphological presentation in the skin of color.

Safety and Efficacy of 25 mg/kg and 35 mg/kg vs 10 mg/kg Rifampicin in Pulmonary TB: A Phase IIb Randomized Controlled Trial.

Background: Globally, no trial data are available on head-to-head comparison between 10 mg/kg and 25/35 mg/kg rifampicin in treating pulmonary tuberculosis during study initiation. Methods: A multicentric, phase IIb randomized trial recruited 333 new culture-positive, drug-sensitive adult patients with pulmonary tuberculosis to compare safety and efficacy of high-dose rifampicin (R25/R35), against conventional dose (R10) given daily for 8 weeks followed by standard doses for 16 weeks. Main outcomes were treatment-emergent grade 3/4 adverse events (AEs) and time-to-culture conversion in liquid media, assessed by division of AIDS system for grading the severity of adverse events division of AIDS criteria and Kaplan-Meier methods. Results: In a modified intention-to-treat population of 323 patients (R10: 105/R25: 112/R35: 106), grade 3/4 AEs were reported in 34 patients (R10: 9.5% [10/105], R25: 9.8% [11/112], R35: 12.3% [13/106]) during the intensive phase. Among 23 patients (R10: 3.8% [4/105], R25: 6.3% [7/112], R35: 11.3% [12/106]) with grade 3/4 hepatotoxicity, 15 (R10: 1.9% [2/105], R25: 3.6% [4/112], R35: 8.5% [9/106]) had grade 3/4 hyperbilirubinemia and 9 patients (R10: 1.0% [1/105], R25: 0.9% [1/112], R35: 6.6% [7/106]) developed clinical jaundice. Significant differences observed only between R10 and R35 with hepatotoxicity (P = .039), hyperbilirubinemia (P = .031), clinical jaundice (P = .032), and treatment interruption (P = .039). Eighteen serious AEs and 6 deaths (R10: 3/R25: 1/R35: 2) occurred during study period. Time to stable culture conversion in liquid media was faster in R25 (adjusted hazard ratio, 1.71; 95% confidence interval [CI], 1.26-2.31 [solid: 1.97; 95% CI, 1.46-2.67]) and R35 (1.81; 95% CI, 1.33-2.48 [solid: 2.24; 95% CI, 1.64-3.06]), than R10 (34 vs 44 days). R25 had no failure/relapse. Conclusions: Hepatotoxicity, clinical jaundice, and treatment interruptions occurred significantly higher with R35 than R10. Because R25 was comparably safe as R10 and also highly efficacious than R10, it may be considered for implementation. Clinical Trials Registration. CTRI/2017/12/010951.

A Comparative Study of the Efficacy of Intralesional 5 Fluorouracil vs Combination of 5 Fluorouracil with Triamcinolone Acetonide in Keloids.

Context: Keloids are defined as scars that invade the adjacent tissues and rarely regress. In recent years, antimitotic drugs have been used in the management of keloids with promising results. This study highlights the effectiveness of 5-fluorouracil (5-FU) in keloids. Aims: To study the efficacy of intralesional 5-FU in keloids as a solo agent and in combination with triamcinolone acetonide and to study the side effects of both the drugs. Methods and Materials: A total of 30 patients with keloids were randomly allocated into two groups. Group A received 50 mg/mL of 5-FU intralesionally. Group B patients received a combination of 40 mg/mL of intralesional triamcinolone acetonide and 50 mg/mL of 5-FU. The patients were observed for immediate and delayed complications and the treatment was continued for a total of 3 months. Statistical Analysis Used: ANOVA, Mann-Whitney test, Fisher's test, Chi-square test. Results: The patients in both groups showed a significant reduction in the size and thickness of the lesions. The reduction in the length of keloid was highly significant in both the groups but in comparison, there was no statistically significant difference in the reduction of lesions among both the groups. Hence, both modalities of treatment can be claimed to be equally efficacious. The therapeutic response was good to excellent in most patients with only one patient opting out of the therapy in the 5-FU group due to the inability to tolerate the pain. The common side effects noted were pain, itching, ulceration, burning sensation, and bulla formation. Conclusions: 5-FU, both as a single agent or in combination with steroids is equally efficacious in reducing the keloid size. The side effects are lesser with the combination group.

A rare presentation of pseudoepitheliomatous keratotic and micaceous balanitis with malignant transformation.

Pseudoepitheliomatous keratotic and micaceous balanitis (PKMB) is a rare nonvenereal penile condition with a risk of malignant transformation. We report a case of PKMB in a 45-year-old male who presented with multiple keratotic growths over his glans penis after circumcision for long-standing phimosis. Histopathology revealed pseudoepitheliomatous hyperplasia and atypical cells. He was successfully treated with wide local excision.

Protonated state and synergistic role of Nd3+ doped barium cerate perovskite for the enhancement of ionic pathways in novel sulfonated polyethersulfone for H2/O2 fuel cells.

In recent decades, there has been a need for novel advancement of sustainable non-fluorinated polymer electrolyte membranes for proton exchange membrane fuel cell (PEMFC) applications. The set forth strategy aims to ameliorate proton conduction of sulfonated polyethersulfone (SPES) polymer membranes with a distinct mixture of barium cerate (BCO) and neodymium-doped barium cerate (BCNO) perovskites developing cationic composite membranes (CCMs) prepared through a technique of solvent casting. The CCMs were subjected to analysis of their mechanical, structural, chemical compositional, thermal, morphological, oxidative, physicochemical, electrochemical and fuel cell polarization performance respectively. Acceptor doping of the trivalent neodymium group at the B site of BCO increases the number of oxygen vacancies and improves ionic conduction. The CCM of neodymium-doped barium cerate demonstrates a higher proton conductivity of 42.2 mS cm-1 with a lower activation energy of 6.80 kJ mol-1 at 80 °C. The maximum current density and power density with the OCV of 0.93 V for the neodymium-doped barium cerate membrane are 397 mA cm-2 and 117 mW cm-2, which is 1.8 times greater than that of the pure SPES membrane. On the basis of polarization performance, the SPES membrane with neodymium-doped barium cerate has great potential in highly-efficient PEMFC applications.

A non-edible waste as a potential sorptive media for removal of herbicide from the watershed.

A non-edible waste, from biodiesel processing industry is being turned to carbonaceous material (biochar) using slow pyrolysis. The material was found to be amorphous with hydroxyl, methyl, carbonyl and carboxyl functional groups onto the surface. The influencing parameters, namely adsorbate concentration (0.05-5 mg/l), biochar loading (0.02-0.4 g), pH(3-12) and particle sizes (0.03-0.13 mm) were studied to observe the effect on the sorption of simazine using biochar. A multivariate optimization using central composite design in response surface methodology was performed employing desirability function. The optimized biosorption efficiency (B%) and capacity qe was found to be 91.98 % and 0.83 mg/g respectively with the optimized parameters as 3.76 mg/l of adsorbate concentration, 0.12 g of biochar loading, pH of 5.26 and 0.0535 mm of particle size. The simazine adsorption phenomena were found to be multilayer heterogeneous sorption based on Langmuir and Freundlich models. The kinetics investigation shows that chemisorption was involved for the transfer of simazaine to the surface of biochar with three distinct intra particulate diffusional zones. An adsorption process requires activation energy of 11.27 kJ/mol and the negative magnitude of ΔH* indicates the exothermicity involved in the process.

Proteomic and transcriptomic approaches to identify resistance and susceptibility related proteins in contrasting rice genotypes infected with fungal pathogen Rhizoctonia solani.

The devastating sheath blight disease caused by Rhizoctonia solani Kuhn (teleomorph: Thanatephorus cucumeris) causes major yield loss in most rice growing regions of the world. In this study, two moderately tolerant and four susceptible genotypes of rice were selected for R. solani induced proteome analysis using two-dimensional polyacrylamide gel electrophoresis. Forty five differentially expressed proteins (DEPs) were identified and analyzed by Mass Spectrometry. Based on their functions, these proteins were classified into different groups, viz., photosynthesis, resistance and pathogenesis, stress, cell wall metabolism and cytoskeleton development associated proteins, and hypothetical or uncharacterized proteins. Expression of 14 genes encoding DEPs was analyzed by quantitative PCR which showed consistency in transcripts and genes expression pattern. Furthermore, the expression of 16 other genes involved in diverse biological functions was analyzed. Up-regulation of these genes in the tolerant genotype Pankaj during sheath blight disease suggested efficient genetic regulation of this cultivar under stress. Also, expression analysis of conserved microRNAs (miRNAs) and their target genes revealed important role of miRNAs in post-transcriptional gene regulation during development of rice sheath blight disease. Genome-wide discovery of miRNAs and further characterization of DEPs and genes will help in better understanding of the molecular events during sheath blight disease development in rice.

Recurrent, nodular lesions over the vulva: A diagnostic challenge.

Angiokeratomas are benign tumors characterized by proliferation and dilatation of blood vessels in the upper dermis. They are divided into widespread and localized forms. The localized forms are further classified as angiokeratoma of Fordyce, angiokeratoma circumscriptum neviforme, circumscribed angiokeratoma, and angiokeratoma of Mibelli, of which angiokeratoma of Fordyce is the most common. A 38-year-old female, with no systemic comorbidities presented with recurrent, asymptomatic dark, raised lesions over the vulva for 15 years, progressively increasing in size and number. There were no similar complaints in the family or spouse. On examination, multiple pedunculated hyperpigmented papules and nodular lesions with a verrucous surface were present over the bilateral labia majora and pubic area. Per speculum examination revealed no abnormalities. The oral, conjunctival, and genital mucosae were normal. There were no similar lesions elsewhere over the body. Histopathological examination revealed marked dilatation of papillary dermal vessels forming large, blood-filled cavernous channels, suggestive of angiokeratoma. The lesions were removed using radiofrequency. We present this case due to the rarity of its occurrence and to emphasize the importance of ruling out nonvenereal causes of genital lesions.

A Clinicopathological and Dermoscopic Correlation of Seborrheic Keratosis.

BACKGROUND: Seborrheic keratosis (SK) is the most common benign epidermal tumor of the skin. Even though SK has been well characterized clinically, dermoscopically, and histopathologically, data regarding clinical dermoscopic and histopathological correlation of different types of SK are inadequate. AIM: We carried out this study to establish any correlation between the clinical, dermoscopic, and histopathological appearance of SK and its variants. METHODS: This was a descriptive study. Patients with SK were evaluated with respect to age, sex, family history of similar lesions, site of lesions, and symptoms associated with the lesions. Dermoscopy was performed in all cases. Biopsies were taken from the lesions and assessed for histopathology. RESULTS: The most common age group affected by SK was 31-50 years (42%). A female preponderance of 76% was seen. Majority of our patients had a positive family history (62%), though Sun exposure was not seen to be a major factor. The most common clinical variant was common SK (CSK) (46%). The most common dermoscopic findings seen in CSK were comedo-like (CL) openings, fissures and ridges (FR), and milia-like (ML) cysts. Dermatosis papulosa nigra and pedunculated SK had characteristic FR and CL openings on dermoscopy. Stucco keratoses showed network-like (NL) structures and sharp demarcation. CL opening on dermoscopy corresponded to papillomatosis and pigmentation, ML cysts corresponded to horn cysts, FR corresponded to papillomatosis, and NL structures corresponded to an increase in basal layer pigmentation. CONCLUSIONS: This study emphasizes the use of dermoscopy in improving the diagnostic accuracy of SK. The correlation between the various histological and dermoscopic features is described.

Effectiveness of Onsite Nurse Mentoring in Improving Quality of Institutional Births in the Primary Health Centres of High Priority Districts of Karnataka, South India: A Cluster Randomized Trial.

BACKGROUND: In India, although the proportion of institutional births is increasing, there are concerns regarding quality of care. We assessed the effectiveness of a nurse-led onsite mentoring program in improving quality of care of institutional births in 24/7 primary health centres (PHCs that are open 24 hours a day, 7 days a week) of two high priority districts in Karnataka state, South India. Primary outcomes were improved facility readiness and provider preparedness in managing institutional births and associated complications during child birth. METHODS: All functional 24/7 PHCs in the two districts were included in the study. We used a parallel, cluster randomized trial design in which 54 of 108 facilities received six onsite mentoring visits, along with an initial training update and specially designed case sheets for providers; the control arm received just the initial training update and the case sheets. Pre- and post-intervention surveys were administered in April-2012 and August-2013 using facility audits, provider interviews and case sheet audits. The provider interviews were administered to all staff nurses available at the PHCs and audits were done of all the filled case sheets during the month prior to data collection. In addition, a cost analysis of the intervention was undertaken. RESULTS: Between the surveys, we achieved coverage of 100% of facilities and 91.2% of staff nurse interviews. Since the case sheets were newly designed, case-sheet audit data were available only from the end line survey for about 80.2% of all women in the intervention facilities and 57.3% in the control facilities. A higher number of facilities in the intervention arm had all appropriate drugs, equipment and supplies to deal with gestational hypertension (19 vs.3, OR (odds ratio) 9.2, 95% C.I 2.5 to33.6), postpartum haemorrhage (29 vs. 12, OR 3.7, 95% C.I 1.6 to8.3); and obstructed labour (25 vs.9, OR 3.4, 95% CI 1.6 to8.3). The providers in the intervention arm had better knowledge of active management of the third stage of labour (82.4% vs.35.8%, AOR (adjusted odds ratio) 10, 95% C.I 5.5 to 18.2); management of maternal sepsis (73.5% vs. 10.9%, AOR 36.1, 95% C.I 13.6 to 95.9); neonatal resuscitation (48.5% vs.11.7%, AOR 10.7, 95% C.I 4.6 to 25.0) and low birth weight newborn care (58.1% vs. 40.9%, AOR 2.4, 95% C.I 1.2 to 4.7). The case sheet audits revealed that providers in the intervention arm showed greater compliance with the protocols during labour monitoring (77.3% vs. 32.1%, AOR 25.8, 95% C.I 9.6 to 69.4); delivery and immediate post-partum care for mothers (78.6% vs. 31.8%, AOR 22.1, 95% C.I 8.0 to 61.4) and for newborns (73.9% vs. 32.8%, AOR 24.1, 95% C.I 8.1 to 72.0). The cost analysis showed that the intervention cost an additional $5.60 overall per delivery. CONCLUSIONS: The mentoring program successfully improved provider preparedness and facility readiness to deal with institutional births and associated complications. It is feasible to improve the quality of institutional births at a large operational scale, without substantial incremental costs. TRIAL REGISTRATION: ClinicalTrials.gov NCT02004912.

Surgical Outcome in Patients Taking Concomitant or Recent Intake of Oral Isotretinoin: A Multicentric Study-ISO-AIMS Study.

BACKGROUND: The current standard recommendation is to avoid surgical interventions in patients taking oral isotretinoin. However, this recommendation has been questioned in several recent publications. AIM: To document the safety of cosmetic and surgical interventions, among patients receiving or recently received oral isotretinoin. MATERIALS AND METHODS: Association of Cutaneous Surgeons, India, in May 2012, initiated this study, at 11 centers in different parts of India. The data of 183 cases were collected monthly, from June 2012 to May 2013. Of these 61 patients had stopped oral isotretinoin before surgery and 122 were concomitantly taking oral isotretinoin during the study period. In these 183 patients, a total of 504 interventions were performed. These included[1] 246 sessions of chemical peels such as glycolic acid, salicylic acid, trichloroacetic acid, and combination peels;[2] 158 sessions of lasers such as ablative fractional laser resurfacing with erbium-doped yttrium aluminum garnet and CO2, conventional full face CO2 laser resurfacing, laser-assisted hair reduction with long-pulsed neodymium-doped yttrium aluminum garnet, diode laser, and LASIK surgery;[3] 27 sessions of cold steel surgeries such as microneedling, skin biopsy, subcision, punch elevation of scars, excision of skin lesion, and wisdom tooth extraction;[4] 1 session of electrosurgery. RESULTS: No significant side effects were noted in most patients. 2 cases of keloid were documented which amounted to 0.4% of side effects in 504 interventions, with a significant P value of 0.000. Reversible transient side effects were erythema in 10 interventions and hyperpigmentation in 15. CONCLUSION: The study showed that performing dermatosurgical and laser procedures in patients receiving or recently received isotretinoin is safe, and the current guidelines of avoiding dermatosurgical and laser interventions in such patients taking isotretinoin need to be revised.

Validation of artificial neural network models for predicting biochemical markers associated with male infertility.

UNLABELLED: Seminal fluid is the secretion from many glands comprised of several organic and inorganic compounds including free amino acids, proteins, fructose, glucosidase, zinc, and other scavenging elements like Mg(2+), Ca(2+), K(+), and Na(+). Therefore, in the view of development of novel approaches and proper diagnosis to male infertility, overall understanding of the biochemical and molecular composition and its role in regulation of sperm quality is highly desirable. Perhaps this can be achieved through artificial intelligence. This study was aimed to elucidate and predict various biochemical markers present in human seminal plasma with three different neural network models. A total of 177 semen samples were collected for this research (both fertile and infertile samples) and immediately processed to prepare a semen analysis report, based on the protocol of the World Health Organization (WHO [2010]). The semen samples were then categorized into oligoasthenospermia (n=35), asthenospermia (n=35), azoospermia (n=22), normospermia (n=34), oligospermia (n=34), and control (n=17). The major biochemical parameters like total protein content, fructose, glucosidase, and zinc content were elucidated by standard protocols. All the biochemical markers were predicted by using three different artificial neural network (ANN) models with semen parameters as inputs. Of the three models, the back propagation neural network model (BPNN) yielded the best results with mean absolute error 0.025, -0.080, 0.166, and -0.057 for protein, fructose, glucosidase, and zinc, respectively. This suggests that BPNN can be used to predict biochemical parameters for the proper diagnosis of male infertility in assisted reproductive technology (ART) centres. ABBREVIATIONS: AAS: absorption spectroscopy; AI: artificial intelligence; ANN: artificial neural networks; ART: assisted reproductive technology; BPNN: back propagation neural network model; DT: decision tress; MLP: multilayer perceptron; PESA: percutaneous epididymal sperm spiration; RBFN: radical basis function network; SRNN: simple recurrent neural network; SVM: support vector machines; TSE: testicular sperm extraction; WHO: World Health Organization.

Screening, production, optimization and characterization of ß-glucosidase using microbes from shellfish waste.

An extracellular ß-glucosidase was isolated from Proteus mirabilis VIT117 found to be growing on prawn shells. The enzyme production was found to be enhanced (14.58 U/ml) when the culture was maintained at pH 9 and provided with sorbitol as carbon source, yeast extract as nitrogen source and incubated at 37 °C for approximately 72 h. Statistical methods like Plackett-Burman and RSM were also applied here to study the effects of different combinations of growth parameters for the bacteria, where the most significant parameters were found to be inoculum size, pH, yeast extract, incubation time and sorbitol. The optimum concentrations of inoculum size, pH and yeast extract determined by RSM were 2 %, 9 and 2 %, respectively. Partial purification of the protein was done by ammonium sulfate precipitation, followed by dialysis, gel filtration chromatography and SDS-PAGE. The enzyme was found to have a molecular weight of approximately 50 kDa and was observed to be most active at 37 °C in pH 9, with a sharp decline in the enzyme activity when temperature or the pH was increased. Enzyme kinetics study was performed to understand the catalytic behavior of the enzyme and it was found that our ß-glucosidase had 5.613 U/ml and 0.082 mM as V max and K m values, respectively.

An atypical presentation of antiphospholipid antibody syndrome.

Cutaneous manifestations in antiphospholipid antibody syndrome (APS) though common, are extremely diverse and it is important to know which dermatological finding should prompt consideration of antiphospholipid syndrome. The cutaneous manifestations of APS vary from livedo reticularis to cutaneous necrosis, and systemic involvement is invariably an accomplice in APS. Cutaneous ulcers with sharp margins can be seen in APS and they are usually seen on the legs. This case had an atypical presentation, as the initial presentation was painful necrotic ulcers over the legs, which resembled pyoderma gangrenosum and she had no systemic manifestations. There was no history of any arterial or venous thrombosis or any abortions. Antiphospholipid syndrome can be tricky to diagnose when cutaneous lesions are atypical. Nonetheless, it is very important to pin down this syndrome early due to its systemic complications.

Assessment of facility readiness and provider preparedness for dealing with postpartum haemorrhage and pre-eclampsia/eclampsia in public and private health facilities of northern Karnataka, India: a cross-sectional study.

BACKGROUND: The maternal mortality ratio in India has been declining over the past decade, but remains unacceptably high at 212 per 100,000 live births. Postpartum haemorrhage (PPH) and pre- eclampsia/eclampsia contribute to 40% of all maternal deaths. We assessed facility readiness and provider preparedness to deal with these two maternal complications in public and private health facilities of northern Karnataka state, south India. METHODS: We undertook a cross-sectional study of 131 primary health centres (PHCs) and 148 higher referral facilities (74 public and 74 private) in eight districts of the region. Facility infrastructure and providers' knowledge related to screening and management of complications were assessed using facility checklists and test cases, respectively. We also attempted an audit of case sheets to assess provider practice in the management of complications. Chi square tests were used for comparing proportions. RESULTS: 84.5% and 62.9% of all facilities had atleast one doctor and three nurses, respectively; only 13% of higher facilities had specialists. Magnesium sulphate, the drug of choice to control convulsions in eclampsia was available in 18% of PHCs, 48% of higher public facilities and 70% of private facilities. In response to the test case on eclampsia, 54.1% and 65.1% of providers would administer anti-hypertensives and magnesium sulphate, respectively; 24% would administer oxygen and only 18% would monitor for magnesium sulphate toxicity. For the test case on PPH, only 37.7% of the providers would assess for uterine tone, and 40% correctly defined early PPH. Specialists were better informed than the other cadres, and the differences were statistically significant. We experienced generally poor response rates for audits due to non-availability and non-maintenance of case sheets. CONCLUSIONS: Addressing gaps in facility readiness and provider competencies for emergency obstetric care, alongside improving coverage of institutional deliveries, is critical to improve maternal outcomes. It is necessary to strengthen providers' clinical and problem solving skills through capacity building initiatives beyond pre-service training, such as through onsite mentoring and supportive supervision programs. This should be backed by a health systems response to streamline staffing and supply chains in order to improve the quality of emergency obstetric care.

Clinico-etiological study of 30 erythroderma cases from tertiary center in South India.

BACKGROUND: Erythroderma is a morphological reaction pattern of skin having many underlying causes and finding the etiology helps in the proper management of erythroderma cases. AIM: To evaluate the clinical profile, etiology of erythroderma and to correlate clinical diagnosis with histopathology. MATERIALS AND METHODS: This study was performed at the department of dermatology, Father Muller Medical College and Hospital, Mangalore, South India. We studied 30 consecutive cases of erythroderma with respect to the epidemiological, clinical and histological data. Clinico-histological correlation was analyzed for etiology of erythroderma. RESULTS: The mean age of onset was 52.3 years with a male to female ratio of 14:1. In addition to erythroderma, other co-existent features included pruritus, fever, lymphadenopathy, and edema. Of the pre-existing dermatoses, psoriasis was the most common (33.3%) disease followed by eczema (20%), atopic dermatitis (6.6%), pityriasis rubra pilaris (3.3%) and drug-induced erythroderma (16.6%). In 16.6% of cases, etiology could not be ascertained. Clinico-histopathological correlation could be established in 73.3% of cases. CONCLUSION: Clinical features were identical irrespective of etiology. Detailed clinico-histopathological examination helps to establish the etiology of erythroderma.