The supraclavicular approach to decompression of the thoracic outlet.

Surgical decompression of the thoracic outlet, along with treatment of the involved nerve or vessel, is the accepted treatment modality when indicated. Although neurogenic thoracic outlet syndrome (TOS) is often operated via the axillary approach and venous TOS via the paraclavicular approach, arterial TOS is almost always operated via the supraclavicular approach. The supraclavicular approach provides excellent access to the artery, brachial plexus, phrenic nerve, and the cervical and/or first ribs, along with any bony or fibrous or muscular abnormality that may be causing compression of the neurovascular structures. Even for neurogenic TOS, for which the axillary approach offers good cosmesis, the supraclavicular approach helps with adequate decompression while preserving the first rib. This approach may also be sufficient for thin patients with venous TOS. For arterial TOS, a supraclavicular incision usually suffices for excision of bony abnormality and repair of the subclavian artery.

Dermoscopy in Leprosy: A Clinical and Histopathological Correlation Study.

BACKGROUND: Leprosy, an insidious infectious granulomatous disease, is diagnosed traditionally through clinical examination coupled with skin smears and histopathology. It has myriad clinical presentations that pose diagnostic challenges. Lately, dermoscopy has emerged as a rapid, noninvasive diagnostic modality for many dermatoses. OBJECTIVES: We evaluated the dermoscopic findings of various manifestations of leprosy and correlated them with clinical and histopathological features. METHODS: This prospective, cross-sectional study was conducted in our skin outpatient department for a period of 1 year. Patients newly diagnosed as having leprosy or those undergoing leprosy treatment for less than 6 months were included. The most representative lesion was dermoscopically evaluated and later biopsied. RESULTS: We included 73 patients in the study. Results indicated an obvious correlation between dermoscopic findings and histopathology. We noted orangish yellow and white structureless areas, steadily throughout the spectrum, depicting dermal granuloma. Additionally, we observed focal vascular structures such as branching, linear, and crown vessels that result from the pressure of granuloma pushing the dilated vessels upwards. The relative absence of skin appendages aided in differentiating leprosy from other granulomatous disorders. Novel findings of our study were the detection of a branch-like pattern of clofazimine-induced pigmentation on dermoscopy and orange globules on onychoscopy. Other unique findings included violaceous structureless areas, characteristic large telangiectatic vessels, follicular plugging, star-shaped silvery-white scaling, and white globules in type 1 reaction; white shiny steaks were observed in patients with borderline lepromatous leprosy, and central white dots and keratotic plugs were observed in patients with histoid leprosy. CONCLUSIONS: Dermoscopy, as a noninvasive modality, could aid in the quick diagnosis of leprosy and should be used as a handy tool to complement other investigative tools for this disease.

Endocrinological Testicular Dysfunction in Patients with Lepromatous Leprosy and the Impact of Disease on Patient's Quality of Life.

INTRODUCTION: Leprosy or Hansen's disease poses a drastic impact on the quality of life in affected patients even after successful completion of treatment. The involvement of the endocrine system in leprosy is usually insidious, silent, and under-reported, especially the testicular dysfunction. AIMS AND OBJECTIVES: The present study was aimed at evaluating the abnormalities of the primary testicular hormone testosterone and the gonadotrophins LH and FSH in male patients affected with lepromatous leprosy and assessing the impact of the disease on quality of life (QOL). MATERIALS AND METHODS: The study included 43 married male patients diagnosed with lepromatous leprosy. Careful history taking and examination for symptoms of testicular dysfunction were done. Serum concentrations of total testosterone, FSH, and LH were noted. The QOL was evaluated using the WHO Quality of Life-BREF (WHOQoL-BREF). RESULTS: The most common clinical manifestation of testicular dysfunction was reduced or loss of libido reported in 12 (27.9%) patients followed by gynaecomastia in 7 (16.3%). Ultrasonographic (USG) analysis revealed reduced testicular volume in 31 (72.1%) patients, and average testicular volume was 11.9 ± 4.9 mL each. Seventeen (39.5%) patients had low serum testosterone levels, 9 (20.9%) had high serum FSH level, and 11 (25.6%) high LH levels. There was a significant negative correlation between testosterone level and FSH as well as LH. There was also a significantly positive correlation between testicular volume and testosterone level. Symptomatic patients with gynaecomastia/gynaecothelia had higher hormonal derangement than those who had other symptoms. On QOL, most patients scored lowest on the domain of "social relationships" (including sexual wellbeing) followed by "psychological health". CONCLUSION: We found a high rate of USG diagnosed testicular atrophy in lepromatous leprosy patients. Therefore, every leprosy patient should be thoroughly examined clinically to rule out features of testicular dysfunction. Testicular function tests should be routinely carried out in all leprosy patients to arrive at an early diagnosis. Leprosy is found to affect all domains of a patient's quality of life.

Anterior Ectopic Cilia with Myopia and Lichen Nitidus: A Rare Case Report with Dermoscopic Findings.

Ectopic cilia, or lash follicles situated over abnormal sites, are an extremely rare entity. Here, we report the case of a 6-year-old-boy who presented with ectopic cilia over the left upper eyelid along with a positive family history. Dermoscopy revealed discreet terminal hair emerging from the individual hair follicles surmounted over a diffuse structureless whitish-yellow zone and a few vellus hairs in the surrounding normal skin. These hairs, on histopathological examination, had multiple pilosebaceous follicular units embedded in a desmoplastic stroma with multiple eccrine sweat glands. Other incidental findings included lichen nitidus and myopia.

A comparative study of the efficacy and safety of intralesional measles, mumps, and rubella vaccine versus intralesional vitamin D3 for the treatment of warts in children.

BACKGROUND: Intralesional vitamin D3 has recently emerged as a new treatment for cutaneous warts. The use of the measles, mumps, and rubella (MMR) vaccine for this purpose is an established modality. However, relevant data on the efficacy of either the MMR vaccine or vitamin D3 as immunotherapy for cutaneous warts in the pediatric population are limited. OBJECTIVES: To compare the efficacy and safety of intralesional injections of MMR vaccine to intralesional injections of vitamin D3 in children aged 8-16 years with multiple warts. METHODS: A total of 74 children were randomly allocated into two groups. Group A patients received intralesional MMR vaccine into the largest wart, and group B received intralesional vitamin D3 into the largest wart. The injections were repeated every 4 weeks until clearance or for a maximum of three treatments. After the last injection, children were followed up every 2 weeks for 3 months, and at the sixth month, a final clinical assessment was conducted. RESULTS: Of 74 children, 60 completed the study, with 30 children in each group. Complete clearance of the injected wart was observed in 26 (86.67%) patients in the MMR group (group A) and 23 (76.7%) patients in the vitamin D3 group (group B). Distant warts cleared in 23 (76.7%) patients in group A compared to 20 (66.6%) patients in group B. There was no significant difference between groups. No recurrence was seen in group A, whereas two (6.6%) children in group B exhibited recurrence in the ensuing 6-month follow-up. The most common adverse events were injection site pain and swelling. CONCLUSION: Both intralesional MMR and vitamin D3 are safe, generally well-tolerated, and equally effective in children for the treatment of cutaneous warts.

Analyzing trend and forecasting of rainfall changes in India using non-parametrical and machine learning approaches.

This study analyzes and forecasts the long-term Spatio-temporal changes in rainfall using the data from 1901 to 2015 across India at meteorological divisional level. The Pettitt test was employed to detect the abrupt change point in time frame, while the Mann-Kendall (MK) test and Sen's Innovative trend analysis were performed to analyze the rainfall trend. The Artificial Neural Network-Multilayer Perceptron (ANN-MLP) was employed to forecast the upcoming 15 years rainfall across India. We mapped the rainfall trend pattern for whole country by using the geo-statistical technique like Kriging in ArcGIS environment. Results show that the most of the meteorological divisions exhibited significant negative trend of rainfall in annual and seasonal scales, except seven divisions during. Out of 17 divisions, 11 divisions recorded noteworthy rainfall declining trend for the monsoon season at 0.05% significance level, while the insignificant negative trend of rainfall was detected for the winter and pre-monsoon seasons. Furthermore, the significant negative trend (-8.5) was recorded for overall annual rainfall. Based on the findings of change detection, the most probable year of change detection was occurred primarily after 1960 for most of the meteorological stations. The increasing rainfall trend had observed during the period 1901-1950, while a significant decline rainfall was detected after 1951. The rainfall forecast for upcoming 15 years for all the meteorological divisions' also exhibit a significant decline in the rainfall. The results derived from ECMWF ERA5 reanalysis data exhibit that increasing/decreasing precipitation convective rate, elevated low cloud cover and inadequate vertically integrated moisture divergence might have influenced on change of rainfall in India. Findings of the study have some implications in water resources management considering the limited availability of water resources and increase in the future water demand.