Topical Diclofenac to Manage Opioid-Refractory Pain in a Rare Pancreatic Fibrosarcoma.

Pancreatic cancer is often diagnosed at an advanced stage and is frequently associated with severe pain. Traditional pain management in this condition may be improved with the use of topical diclofenac. A 39-year-old man with advanced pancreatic fibrosarcoma metastatic to the thoracic spine presented to the hospital with severe abdominal pain refractory to escalating doses of opioids. A celiac plexus block produced significant, yet inadequate, pain reduction. Satisfactory pain control and opioid de-escalation were ultimately achieved with the application of topical diclofenac gel to an area of bony metastasis. This case illustrates the potential for pain control using topical diclofenac in patients with pancreatic soft tissue tumors and vertebral metastases. Topical diclofenac may exert antitumoral effects and targeted application may improve absorption, leading to improved pain control. The use of topical diclofenac for pain management in metastatic pancreatic cancer presents an interesting tool that should be considered in similar cases.

Applications of visualizing cochlear basal turn in cochlear implantation.

Objective: To report a reliable method in obtaining optimal cochlear basal turn and cross-section (c/s) of internal auditory canal (IAC) supporting Cochlear implantation (CI) procedure. Materials and Methods: Computer tomography (CT) and magnetic resonance image (MRI) scans of potential CI candidates from 2018 to 2022 from the tertiary center were considered for analysis. Slicer software was used in three-dimensional (3D) segmentation of inner ear and for capturing the cochlear basal turn. Results: A total of 1932 head scans were made available for the analysis and out of which 1866 scans had normal anatomy (NA) inner ear. Incomplete partition (IP) type-I was identified in 19 ears, IP type-II in 27 ears, IP type-III in 6 ears, cochlear hypoplasia (CH) type-I in 6 ears, CH type-II in 1 ear, CH type-III in 3 ears, and CH type-IV is 3 ears, and enlarged vestibular aqueduct syndrome in 1 ear. 3D segmented inner ear helped in successfully obtaining the cochlear basal turn and the c/s of IAC in all anatomical types. Time taken to capture the cochlear basal turn with the help of 3D segmented inner ear was <1 min. Within the NA category, five cases showed scalar ossification, and its extent was identified in the cochlear basal turn. Conclusion: The identification and the extent of ossification in the scala tympani, shape of the basal turn, and the cochlear size measurement in cochlear basal turn has high clinical relevance as this helps in surgical planning and in choosing appropriate electrode length. Level of evidence: Level 2 to the best of our understanding.

Periodontal Disease Pathogens, Pathogenesis, and Therapeutics: The CRISPR-Cas Effect.

Periodontal disease (PD) is an immune-inflammatory disease affecting the supporting structures of the teeth, which results in progressive destruction of the hard and soft tissues surrounding teeth, ultimately resulting in tooth loss. The primary etiological factor for this disease is the presence of pathogenic microorganisms. Pathogenic bacteria face antagonistic conditions and foreign DNA components during the infection stage and depend on defense mechanisms such as clustered regularly interspaced short palindromic repeats (CRISPR)-Cas to counter them. Virulence genes regulated by the CRISPR-Cas system are often expressed by bacteria as part of the stress response to the presence of stress conditions and foreign elements. There is ever-growing evidence regarding the role of CRISPR-Cas in virulence of periodontal pathogens. The same CRISPR-Cas system may also be targeted to reduce bacterial virulence and it may also be utilized to develop diagnostic and therapeutic strategies for prevention and control of PD progression. This review article describes the CRISPR-Cas systems in the periodontal dysbiotic microbial communities, their role in the virulence of periodontal pathogens, and their potential role in understanding the pathogenesis of periodontitis and treatment of PD.

Ewing's Sarcoma of the Talus in an Adolescent Female: An Unusual Case Presentation With Review of Literature.

Ewing's sarcoma is an aggressive primary malignant bone tumor that affects long and flat bones and is commonly seen in children and adolescents. The involvement of the foot especially the talus is an extremely rare entity with less than 15 cases reported in the literature. The rarity and atypical symptoms often lead to delays in diagnosis affecting the prognosis and survival. We present a 14-year-old female with pain and swelling of the left ankle for 18 months. She was being treated previously for an ankle sprain and was later suspected of avascular necrosis of the talus, before presenting to us. Clinicoradiology-pathological workup confirmed the diagnosis of Ewing sarcoma of the talus. Further, the metastatic workup revealed multiple skeletal metastases at the time of diagnosis. The metastatic lesion of the right femur required prophylactic fixation, otherwise, the patient was treated with palliative chemotherapy and radiotherapy. Ewing's sarcoma of the foot involving the talus is extremely rare and is a commonly misdiagnosed entity, affecting the overall prognosis of the patient. A high index of suspicion and a multidisciplinary approach is imperative for its early diagnosis and definitive management.

Extremely Rare Primary Spinal Epidural Indolent Mantle Cell Lymphoma: A Case Report With Literature Review.

Lymphomas are malignant tumors arising from lymphoid tissues and can spread to other organs. Primary extra-nodal locations such as the spinal epidural space are less common. Primary spinal epidural lymphoma (PSEL), which can be either Hodgkin's or non-Hodgkin's type, is rare. There are different cell types of Non-Hodgkin's PSEL, among which mantle cell lymphoma (MCL) is extremely rare. MCL can have an aggressive or indolent course. Indolent MCL in the epidural space is not yet reported. We report a case of 20-year-old male who presented with radiating low back pain for six weeks followed by a progressive neurological deficit in both lower limbs for nine days. Magnetic resonance imaging (MRI) revealed spinal epidural tumor extending from L2 to L3. Decompression and subtotal excision biopsy were performed. Histopathology and immunohistochemistry identified indolent MCL. His neurological status improved to normal postoperatively, and he was referred to an oncologist. He is under observation and planned for radiotherapy. At one-year follow-up, he is asymptomatic and doing his regular job abroad.

Primary spinal epidural non-Hodgkin's diffuse large B-cell lymphoma: A case report.

Rare disease like primary spinal epidural diffuse large B-cell lymphoma should be considered as a differential diagnosis in patients presenting with back pain and rapid neurological deterioration in the lower extremities.

Systemic Melioidosis with Acute Osteomyelitis and Septic Arthritis Misdiagnosed as Tuberculosis: A Case Report.

Melioidosis, also called Whitmore's disease, is an infectious disease caused by the bacterium Burkholderia pseudomallei. It is predominantly a disease of tropical climates, especially in Southeast Asia and northern Australia. Due to a wide range of signs and symptoms that can be mistaken for other diseases such as tuberculosis or common forms of pneumonia, patients can be frequently misdiagnosed, which can have adverse consequences and can make management more complicated. This case report elaborates on the clinical course of a middle-aged nondiabetic male patient who presented to our hospital with fever for two months and painful swelling of the right proximal leg for 10 days, following a previous diagnosis of disseminated abdominal tuberculosis made at a different healthcare center. Preliminary investigations confirmed multiple diagnoses of acute osteomyelitis and septic arthritis complicated by multiple hepatic and splenic abscesses. Given the patient was in a state of septic shock at the time of presentation, he was managed as an emergency case and an arthrotomy of the knee joint was performed followed by decompression and drainage of the right proximal tibia. As per standard hospital protocol, the pus and synovial fluid were sent for microbial culture and sensitivity, at which point B. pseudomallei was isolated and the diagnosis was confirmed. Diagnosis of melioidosis requires a high degree of suspicion among clinicians and microbiologists, especially in individuals that have frequent exposure to contaminated soil and water and have a travel history to endemic countries.

Cochlear Implant Surgery by the Veria Technique: How and Why? Experience from 1400 Cases.

The Veria technique for Cochlear implantation is a non mastoidectomy technique which is done throught the endaural route for the cochleostomy with a transcanal tunnel drilled in the posterior canal wall. This technique has been used for implanting in more than 1400 cases. This technique uses a specially designed perforator to make the tunnel in the posterior canal wall. Though the conventional technique has been successful it is more time consuming and is prone to various complications especially in children with small facial recess, cochlear malformations and cochlear rotation. This technique is simple, helps in faster healing and earlier fitting of the processor, is precise thereby minimizing trauma to the facial nerve. The surgery can be performed in infants who have not yet developed the mastoid completely.

Interleukin-11 - its role in the vicious cycle of inflammation, periodontitis and diabetes: A clinicobiochemical cross-sectional study.

CONTEXT: Interleukin-11 (IL-11) is a multifunctional cytokine with a probable regulatory role in the inflamed periodontal tissue. It has also been shown to inhibit the production of potent proinflammatory cytokines like tumor necrosis factor-alpha, IL-6 and IL-1ß in vitro. Type 2 diabetes mellitus, which demonstrates an increase in proinflammatory cytokines, might hypothetically, display a decrease in the levels of IL-11, which down-regulates synthesis of the proinflammatory cytokines. AIMS: This clinicobiochemical cross-sectional study was undertaken to try to interpret the link between IL-11, diabetes and periodontitis and to explore the probable protective role of IL-11. MATERIALS AND METHODS: A total of 90 patients were included in the study and were divided into five groups based on community periodontal index scores and diabetes status. Probing pocket depth and clinical attachment level were measured in all the subjects. Gingival crevicular fluid (GCF) was collected from all the participants using micropipettes and blood samples were collected from subjects in Groups III, IV and V, for analysis of glycated hemoglobin. IL-11 levels were measured in GCF samples by enzyme-linked immunosorbent assay. STATISTICAL ANALYSIS: The data obtained were subjected to statistical analysis. RESULTS: The GCF IL-11 levels decreased from periodontal health to disease and in periodontitis patients with type 2 diabetes with decreasing glycemic control. CONCLUSIONS: Interleukin-11 may play an important role in the modulation of immune response via the reduction of proinflammatory cytokine production and periodontal tissue damage. It was seen in this study that IL-11 could be detected in GCF and the levels of IL-11 in GCF decreased progressively from healthy to periodontitis sites. IL-11 levels were significantly lower in chronic periodontitis group when compared to gingivitis group. The decrease in the levels of IL-11 probably indicates that both diabetes and periodontitis may play a synergistic role in the suppression of protective host responses. The potential of IL-11 as a probable biomarker of inflammation in both periodontal disease and diabetes mellitus is indicated by the changeability of IL-11 levels with the change in periodontal disease status and glycemic control. Further longitudinal studies are needed to validate IL-11 as a "biomarker of inflammation" in periodontal disease and diabetes progression and to prove its role in the connecting link between periodontal disease and type 2 diabetes mellitus.