Total annulus excision tympanoplasty - a solution to recurrent myringitis: double blind randomised trial.

OBJECTIVE: In spite of continuous refinements in tympanoplasty techniques, results are variable, and it is not uncommon to see a discharging eardrum even after a good graft uptake. This study aimed to evaluate the efficacy of total annulus excision tympanoplasty in comparison with conventional underlay tympanoplasty. METHOD: This was a double blinded, randomised, controlled trial performed at a tertiary care centre. After inclusion and exclusion criteria were met, 56 patients were enrolled and randomised, and 28 patients were allocated to each group (group A (conventional tympanoplasty) and group B (total annulus excision)). Patients and evaluators were blind to the procedure performed. RESULTS: Patients in group B (total annulus excision) showed better graft uptake and no discharge with better gains in air conduction thresholds (p < 0.05) when compared with group A (conventional tympanoplasty). CONCLUSION: In view of the advantages it offers, total annulus excision tympanoplasty may be preferred over the conventional techniques in patients with central perforations.

Management of Proximal Thoracic Kyphoscoliosis with Early Myelopathy in a Young Adult with Neurofibromatosis Type 1: A Case Report and Review of Literature.

INTRODUCTION: Neurofibromatosis (NF) 1 is associated with skeletal deformities. Scoliosis is seen in about 10-64% of NF-1 patients. NF-1 may be associated with dystrophic or non-dystrophic type of curve. There are technical difficulties in treating large dystrophic curve with proximal thoracic kyphoscoliosis in NF-1. This case report and subsequent review of literature attempts to provide a line of management for such difficult lesions. MATERIALS AND METHODS: We present a case of 22-year-old male with NF-1 who came to us with gradually progressive upper back deformity and signs of early myelopathy for 2-3 months. The patient had a 100° proximal thoracic kyphosis and 100° scoliosis with no neurological deficit and brisk reflexes. A single stage posterior fixation with three column osteotomy at the apex of the curve was performed. RESULTS: The kyphosis was corrected to 65° from 100, the scoliosis was corrected to 60° from 100. Clinically, the hump in the upper back was visibly reduced. At 1-year follow-up, the patient remained asymptomatic with no loss of correction and implant breakage on X-ray. CONCLUSION: Large dystrophic proximal thoracic kyphoscoliosis is a difficult lesion to treat and can be managed with an all posterior approach, achieving good cosmetic and neurological outcomes, as demonstrated by this case.

Early efficacy and safety of Bedaquiline and Delamanid given together in a "Salvage Regimen" for treatment of drug-resistant tuberculosis.

BACKGROUND: Drug-Resistant Tuberculosis (DR-TB) patients for whom a WHO recommended regimen along with Bedaquiline (BDQ) cannot be prescribed, Delamanid (DLM) was added along with other drugs to provide a "Salvage Regimen". The experience of the Institute in respect of early efficacy and safety of both drugs given together is presented. OBJECTIVE: To ascertain the early efficacy, safety and tolerability of Bedaquline and Delamanid given together as a part of salvage regimen. METHODS: BDQ and DLM were used together to make regimens along with other drugs where four effective anti TB drugs could not be prescribed as per WHO recommendations. Patients were followed up for sputum smear and culture conversion and adverse events during the treatment. RESULTS: In this cohort study, 53 DR-TB patients (Median age-24) were initiated on regimens containing both BDQ and DLM. Sputum smear conversion was seen in 35% and 94% patients at the end of 1st week and 3rd month respectively. 84% patients had culture conversion at the end of 4th month. 29 adverse events (AE) were reported among 17 patients and there were 11 deaths. QTc prolongation more than 500 MS was seen in only 1 patient. CONCLUSION: BDQ and DLM given together in a salvage regimen is efficacious with low rate of adverse events. The combination provides hope to DR-TB patients with limited treatment options and should be provided as a life saving option.

Blood Components Load in Post-operative Neurosurgical Patients Suspected with Disseminated Intravascular Coagulation.

Neurosurgical patients with suspected DIC receive large amount of transfusion support in form of red cell concentrates (RCC), platelet rich plasma (PRP) and fresh frozen plasma (FFP). However, there are very few studies which have studied the effect of blood components load in the outcome of the patient. We conducted a prospective observational study on 61 post operative neurosurgery patients suspected with DIC and had at least one deranged haemostatic parameter namely platelet count, prothrombin time, partial thromboplastin time and thrombin time. Their blood components load was co-related with the outcome and with the hemostatic derangements. Twenty-eight patients died in our study group. 19/28 died patients had DIC. The red cell load was significantly more in patients who died compared to those who were alive (p = 0.041). On the other hand, load of PRP as well as FFP was significantly different between the patients who were alive and dead. This difference was further heightened when the DIC deaths were compared with the other patients. This is especially true for FFP transfusion which was significantly higher in DIC deaths (p = 0.006). Also, the number of FFPs received by neurosurgical patients suspected with DIC was significantly more in patients >2 coagulation abnormalities (p = 0.008). However, no correlation was found between PRP and RCC received and number of coagulation abnormalities present. To conclude, the load of FFP was maximum in patients with DIC deaths and the load of RCC was associated with overall mortality.

Locally aggressive aneurysmal bone cyst of C4 vertebra treated by total en bloc excision and anterior plus posterior cervical instrumentation.

We are presenting a case of cervical (C4) aneurysmal bone cyst in a 13-year-old girl, came to the outpatient department with neck pain and stiffness since 6 months and normal neurology. We did an en bloc excision of locally aggressive tumor through anterior plus posterior approach and stabilization by lateral mass screw fixation and anterior cervical instrumentation. Involvement of several adjacent cervical vertebrae by an aneurysmal bone cyst is rare, and conventional treatment with curettage and bone grafting is most likely to carry a high rate of recurrence and spinal instability. We recommend complete excision of the tumor and instrumentation in a single stage to avoid instability.

To evaluate the role of novel fully covered self-expanding metal stent for endoscopic drainage of infected pancreatic pseudocyst.

INTRODUCTION: Endoscopic ultrasonography-guided transgastric drainage of pancreatic pseudocyst (PPC) is the mainstay of treatment. Drainage can be achieved either by plastic stents or fully covered self-expandable metal stent (FCSEMS). Plastic stents have small lumen diameter, which may limit drainage and may necessitate re-intervention. FCSEMS are easier to deploy and preclude the need to place multiple plastic stents. OBJECTIVE: To evaluate the role of novel FCSEMS for endoscopic drainage of infected PPC. PATIENTS: 10 patients with single symptomatic pseudocyst in proximity to the stomach or duodenum and fever were treated. Pseudocyst drainage was done per protocol. Repeat computed tomography scan after 72 h. Nasocystic drain removed after 3-5 days. PATIENTS were followed-up at every 2 week interval. Stent was removed after complete disappearance of pseudocyst confirmed on imaging. Early (7 days) and late (>7 days) complications were noted and managed accordingly. RESULTS: Technical success and clinical success achieved in all. Early complication: 1/10 (pneumoperitoneum). No late complications observed. Stent were removed without complication after 6-7 week follow-up period ranges from 6 to 8 months. CONCLUSION: Use of FCSEMS for pseudocyst drainage is technically feasible and safe.

Comparison of auditory electrophysiological responses in normal-hearing patients with and without tinnitus.

INTRODUCTION: Tinnitus is a disturbing symptom and is often the main reason for otology referral. It is usually associated with hearing loss of varying aetiology, and is thought to begin in the cochlea, with later abnormal central activity. We hypothesise that tinnitus without hearing loss may be caused by central and subcortical abnormalities and altered outer hair cell function. AIM: To compare the auditory brainstem responses, middle latency responses and otoacoustic emissions in normal-hearing individuals with and without tinnitus. METHODOLOGY: The audiological test results of 25 normal hearing subjects with tinnitus (age 18-45 years) were determined, and compared with those of a control group. RESULTS: A statistically significant difference was found between study group tinnitus ears vs control group ears, as regards wave I latency prolongation, shortening of wave V and absolute I-III and I-V interpeak latency, enlargement of wave Na and Pa amplitude, and distortion product and transient evoked otoacoustic emission signal-to-noise ratios. There was no statistically significant difference between unilateral vs bilateral tinnitus ears. CONCLUSION: The pathogenesis and optimum management of tinnitus are still unclear. It often occurs with primary ear disease, usually associated with hearing loss, but may occur in patients with normal hearing. Observed changes in auditory brainstem and middle latency responses indicate central auditory alterations. Tinnitus involves both peripheral and central activity, and complete audiological and neurophysiological investigation is required. Management should be based on both audiological and neurophysiological findings.

Oral rinse MMP-8 point-of-care immuno test identifies patients with strong periodontal inflammatory burden.

OBJECTIVE: To determine whether oral rinse matrix metalloproteinase (MMP)-8 levels, measured by three different methods, tissue inhibitor of matrix metalloprotease-1 (TIMP-1) levels and elastase activity differentiate subjects with different periodontal condition; and second, to find out if MMP-8 levels were comparable among the methods used. METHODS: MMP-8 levels were analysed with an immunofluorometric method (IFMA), dentoELISA and commercial ELISA. Also TIMP-1 levels and elastase activity were measured. For statistical analysis 214 study subjects were categorized into four groups, specified by the presence and number of moderate (4-5mm) and deep (≥6mm) periodontal pockets, and bleeding on probing percentage. RESULTS: MMP-8 levels especially measured by dentoELISA and adjusted to the number of teeth per subject differentiated the study group with strong periodontal inflammatory burden from groups with lower levels. This was also verified with receiver operating characteristic (ROC) analysis. Elastase activity associated with higher IFMA and dentoELISA MMP-8 levels. IFMA MMP-8/TIMP and dentoELISA MMP-8/TIMP-1 tended to be higher with the increasing level of periodontal inflammatory burden. TIMP-1 levels decreased with increasing age. CONCLUSIONS: Oral rinse MMP-8 together with TIMP-1 analysis may have potential in complementary periodontal diagnostics. dentoELISA can be applied in quantitative oral rinse chair side biomarker diagnostics.

Acute effects of cigarette smoking on pulmonary function.

INTRODUCTION: Chronic smoking related changes in pulmonary function are reflected as accelerated decrease in FEV1 although histologic changes occur in the peripheral bronchi earlier. More sensitive pulmonary function parameters might mirror those early changes and might show a dose response. METHODS: In a randomized three-period cross-over design 57 male adult conventional cigarette (CC)-smokers (age: 45.1+/-7.1 years) smoked either CC (tar:11 mg, nicotine:0.8 mg, carbon monoxide:11 mg [Federal Trade Commission (FTC)]), or used as a potential reduced-exposure product the electrically heated smoking system (EHCSS) (tar:5 mg, nicotine:0.3 mg, carbon monoxide:0.45 mg (FTC)) or did not smoke (NS). After each 3-day exposure period, hematology and exposure parameters were determined preceding body plethysmography. RESULTS: Cigarette smoke exposure was significantly (p<0.0001) higher in CC than in EHCSS and in NS: (carboxyhemoglobin: CC: 6.4+/-1.9%; EHCSS: 1.3+/-0.6%; NS: 0.5+/-0.3%; serum nicotine: CC: 18.9+/-7.4 ng/ml; EHCSS: 8.4+/-4.3 ng/ml; NS: 1.2+/-1.6 ng/ml). Significantly lower in CC than in EHCSS and NS were specific airway conductance (0.22+/-0.09; 0.25+/-0.12; 0.25+/-0.1 1/cmH(2)O x s; CC vs EHCSS: p<0.05; CC vs NS: p<0.01), forced expiratory flow 25% (7.6+/-1.7; 7.8+/-1.7; 7.9+/-1.7 L/s; CC vs EHCSS or NS: p<0.01). Thoracic gas volume (5.1+/-1; 5+/-1.1; 5+/-1.1L/min) changed insignificantly. CONCLUSION: The data indicate acute and reversible effects of cigarette smoke exposures and no-smoking on mid to small size pulmonary airways in a dose dependent manner.

Detection of gingival crevicular fluid MMP-8 levels with different laboratory and chair-side methods.

OBJECTIVE: The aim of the study was to compare four methods for gingival crevicular fluid (GCF) matrix metalloproteinase (MMP)-8 detection. METHODS: Matrix metalloproteinase-8 levels from 20 GCF samples from two periodontally healthy subjects, 18 samples from two patients with gingivitis and 45 samples from six patients with moderate to severe periodontitis, altogether 83 samples, were analysed using (1) a time-resolved immunofluorometric assay (IFMA), (2) an MMP-8 specific chair-side dip-stick test, (3) a dentoAnalyzer device and (4) the Amersham ELISA kit. Western immunoblot using same monoclonal anti-MMP-8 as in IFMA and dentoAnalyzer was used to identify molecular forms of MMP-8 in GCFs. RESULTS: Correlation between IFMA and dentoAnalyzer results calculated with Spearman's correlation coefficient was 0.95 (P = 0.01). The chair-side dip-stick test results were well in line with these assays. Periodontitis sites with unstable characteristics were differentiated with these methods. The Amersham ELISA results were not in line with the findings by other methods. CONCLUSIONS: Immunofluorometric assay and dentoAnalyzer can detect MMP-8 from GCF samples and these methods are comparable. Using Western immunoblot, it was confirmed that IFMA and dentoAnalyzer can detect activated 55 kDa MMP-8 species especially in periodontitis-affected GCF. dentoAnalyzer is among the first quantitative MMP-8 chair-side testing devices in periodontal and peri-implant diagnostics and research.

Application of different methods for the diagnosis of experimental paratuberculosis in goats.

The diagnosis of subclinical paratuberculosis is still considered a major problem worldwide. As part of investigating diagnostic strategies for the paratuberculosis infection, sequential results of various diagnostic methods in a progressive experimental infection in goats were evaluated. Twenty-three goat kids were divided into three groups: the infected, contact and control, comprising 10, five and eight goats respectively. Animals of the infected group were orally inoculated on seven occasions with 5 ml of inoculum containing 2 x 10(9)Mycobacterium avium ssp. paratuberculosis per ml. Lymphoycte proliferation test using johnin PPD detected paratuberculosis infection from 60 days post-infection (DPI) onwards. The johnin PPD was found to be a better antigen for the proliferative assays as compared with the sonicated antigen. The faecal smear examination with acid-fast staining detected more goats as positive than bacterial culture and polymerase chain reaction (PCR). Lipoarabinomannan enzyme-linked immunosorbent assay (ELISA) started detecting infected goats from 150 DPI onwards followed by indirect ELISA and agar gel immunodiffusion from 180 DPI onwards. Histological examination was confirmatory and detected five infected goats as positive.

Evaluation of immunoassay-based MMP-8 detection in gingival crevicular fluid on a point-of-care platform.

A novel immunology-based point-of-care test has been designed to assess the activated form of matrix metalloproteinase-8 (aMMP-8) for diagnosis and monitoring of periodontal diseases. The test has been automated using an analyzer, which quantitatively measures aMMP-8 in 18 min in gingival crevicular fluid (GCF). Fluid samples were collected from healthy, gingivitis-, and periodontitis-affected teeth. The test results from the analyzer were compared with quantitative aMMP-8 immunofluorometric assay (IFMA) and in-house enzyme-linked immunosorbent assay (ELISA) as well as with the periodontal state. Preliminary results of analyzer measurements of these 34 clinical samples showed a good agreement with the results from IFMA and in-house ELISA and with the clinical picture.

Rapid quantitative chairside test for active MMP-8 in gingival crevicular fluid: first clinical data.

In a first pilot field study 64 gingival crevicular fluid (GCF) samples were collected from patients of dental practitioners. The dentists (one orthodontist one periodontist, and one general practitioner) were asked to monitor the respective clinical status of the sites of sampling and to collect, if possible, sulcus fluid samples from healthy as well as affected sites from the same patient. The concentration of activated matrix metalloproteinase-8 (aMMP-8) in the GCF was recorded using a set of monoclonal antibodies and a novel DentoAnalyzer. From all three dental offices the distribution of the aMMP-8 values in GCF showed a congruent pattern, where healthy and periodontitis-affected inflamed sites were clearly disparate.

Progressive immunopathological changes during early stages of experimental infection of goats with Mycobacterium avium subspecies paratuberculosis.

A dose of 10(10) Mycobacterium avium subspecies paratuberculosis was administered orally on seven occasions to produce experimental paratuberculosis infection in 10 5-8-week-old goat kids. Bacteriological, immunological, and histopathological changes, their relationships, and the efficacy of the commonly used diagnostic methods were studied during the progressive disease up to 270 days postinfection (DPI). Significant lymphocyte proliferative responses in the peripheral blood of five goats were detected as early as 60 DPI. A lymphoproliferative test was also performed on lymphocytes purified from different compartments of the guts of five infected and five control goats. Significant proliferative responses were observed in lymphocytes of jejunal compartments of all five goats, of which four had also significant lymphocyte proliferation in the blood. The ileal lymphocytes from two goats, one each at 120 and 270 DPI, had significant proliferation. The histological lesions were mainly observed in the gut-associated lymphoid tissues of the ileocecal valve, the ileum, and the terminal jejunum. Acid-fast bacilli were demonstrated in the lesions of two goats at 60 and 210 DPI. Bacterial culture showed poor sensitivity, detecting positive results for only one goat in the fecal and tissue samples at 210 DPI, whereas polymerase chain reaction (PCR) detected one goat in fecal sample at 210 DPI and two goats in tissue samples at 60 and 210 DPIs, respectively. Enzyme-linked immunosorbent assay and agar gel immunodiffusion test were found to be 100% sensitive from 180 and 210 DPI onwards, respectively.

Evaluation of a LAM ELISA for diagnosis of paratuberculosis in sheep and goats.

A milk and serum ELISA containing lipoarabinomanan (LAM) antigen was evaluated in sheep and goats versus agar gel immunodiffusion (AGID) test and polymerase chain reaction (PCR) using milk and lymph nodes. Milk and serum samples were obtained from six, two, and four flocks with unknown, negative and positive status of infection, respectively. By comparison of serum ELISA activity and PCR results, the positive and negative predictive values were calculated. Receiver operation characteristic (ROC) analysis was used for calculating the specificity and sensitivity at different cut-offs.

Revision total knee arthroplasty: planning, controversies, and management--infection.

Routine blood work that includes ESR, CRP, and glucose levels, and plain radiographs and knee aspirations are obtained from our patients who have clinical suspicion of infection. If the culture result is positive and blood tests suggest infection, the surgical plan is a two-stage revision with an interval period of intravenous antibiotic administration. Risk factors are identified, and the patient's condition optimized. An infectious disease consultant is also involved in the treatment care plan and advises the patient about the best antibiotic, management of proper antibiotic levels, and home care. If culture results are negative, cultures are repeated every week for 3 to 4 weeks after the patient stops taking antibiotics. If the cultures yield positive results, a two-stage revision protocol is initiated. In patients who have 3 to 4 negative culture results, normal blood tests and radiographs, and no history of any immunocompromised state, such as diabetes or rheumatoid arthritis, diagnoses such as polyethylene wear or synovitis can be considered. If patients have any involved risk factor or blood tests, equivocal or suggestive, isotope scintigraphy is requested. We examine tissue in patients with positive scans and equivocal blood test results with clinical suspicion of infection. We prefer an open arthrotomy, which allows us to take multiple specimens for frozen section, assess fixation of the implant, and look for any other signs of infection. If the frozen section reveals more than 10 PMNLs per high-power field, we proceed to stage 1 revision after obtaining intraoperative cultures. If an organism grows in the cultures, stage 2 protocol is initiated. If no cultures are obtained at 7 to 10 days of incubation, we may consider earlier stage 2 revision at 4 to 6 weeks (Fig. 1). In patients in whom the frozen section reveals less than 5 PMNLs per high-power field, component fixation should be assessed, and if they are loose, revision of the knee should be initiated. As with a septic revision, use of antibiotic-impregnated cement can be considered for fixation. If the components are well fixed, a polyethylene tibial tray is exchanged. In either circumstance, intraoperative cultures should be obtained, and if they yield positive results, antibiotics should be continued for 6 to 12 weeks.

Lingual cysticercosis--a case report.

Cysticercosis is unlikely to be the first diagnosis for a swelling over the tongue. In this report we document an unusual case of lingual cysticercosis presenting as an isolated lesion.

CT-generated 3-dimensional models for complex acetabular reconstruction.

Before undergoing complex acetabular reconstruction, 10 patients who met prospectively established criteria for severe acetabular bone deficiency received plain radiographs, computed tomography (CT) scans, and CT-generated 3-dimensional pelvic models. The radiographs, CT scans, and models each were graded according to the American Academy of Orthopaedic Surgery (AAOS) classification for acetabular deficiency. The classifications for the radiographs, CT scans, and models were then compared with findings at surgery. The models predicted acetabular deformity and AAOS classification significantly better than the other imaging modalities. The models agreed with the surgical findings in 9 of 10 cases, compared with 2 of 10 for the CT scans (P = .016) and 4 of 10 for the plain radiographs (P = .063). The models closely predicted the available space for the hemispheric acetabular shells, based on the size of the last reamer used, for the 6 hips reconstructed with standard components. Four patients required custom acetabular components; in 2 of those 4, the need for custom components was not anticipated by plain radiographs or CT scans. Three-dimensional CT-generated acetabular models were found to be useful in preoperative planning of complex acetabular reconstructions.

Chediak-Higashi syndrome--a case report.

Chediak Higashi anomaly is a very rare disorder in which patients suffer frequent and severe pyogenic infections that are secondary to abnormal functions of polymorphonuclear leukocytes, associated with albinism and bleeding tendency. Blume RS and Wolff SM (1972) reported that only 59 cases were diagnosed after the first description of Chediak-Higashi Syndrome in 1943 by Cesar AB (cited by Wintrobe MM Clinical Haematology). As per recent literature available (Internet) last case was reported on 16th July, 1997.

Brush cytology and its comparison with histopathological examination in cases of diseases of the nose.

Nasal cytology is a simple, easy, bloodless and quite reliable investigation. Although its utility was recognized as early as 1927 by Eyerman, it has not yet gained much popularity. Here, an attempt is made to assess its efficacy for the diagnosis of various inflammatory, benign and malignant conditions in 151 cases of common rhinological problems in the M.Y. Group of Hospitals, Indore MP, India. This method can be used as an adjuvant to clinical diagnosis and histopathological diagnosis as an outpatient department (OPD) procedure with the help of a nasal endoscope, as it was found to be a simple, reliable and time-saving procedure for further management. It can also be used as a screening test for the detection of symptomless patients particularly in precancerous lesions.