Myeloid sarcoma presenting as nasopharyngeal mass: A rare clinicopathological scenario.

Myeloid sarcoma (MS) is considered as an extramedullary manifestation of acute myeloid leukemia (AML) with or without concurrent AML. It can present at any age and any site, however, nasopharynx being an extremely rare site of manifestation. MS may precede AML by weeks, months or years, thereby necessitating an early diagnosis and timely intervention and treatment. We report a case of MS in a young female who presented with nasal obstruction and epistaxis for 3 months. The present case also highlights the significance of judicious use of immunohistochemistry panel while dealing with a hematolymphoid neoplasm devoid of expression of B-cell or T cell specific markers in head and neck region.

Macroscopic Extranodal Extension In Oral Squamous Cell Carcinoma-A Subgroup With Poor Survival.

BACKGROUND: Oral cancer portends a significant cause of morbidity and mortality worldwide. Cervical lymph node metastasis with extranodal extension (ENE) is associated with a poor prognosis. There has been accumulating evidence regarding the extent of ENE to be associated with prognosis and survival. AIM: This observational study was performed to analyze the prognostic implication of macroscopic and microscopic ENE in metastatic cervical lymph nodes of oral cavity cancer patients. METHODS: A total of 92 oral cavity cancer patients with pathologically detected ENE were included in this study. Both the groups (macroscopic and microscopic ENE) were compared in terms of overall survival and disease-free survival by using Kaplan -Meier. The pattern of failure was determined by Fischer's exact test. Univariate and multivariate analyses were calculated to determine the significant risk factors of death. RESULTS: The 2 years of disease-free survival and overall survival rates for the whole cohort were 51.2% and 53.9% respectively. The 2-year survival rate for the microscopic group (≤2 mm) and macroscopic (>2 mm) was 72.6% and 0% respectively, while the distal failure rate in microscopic ENE group and macroscopic ENE group was 22.22% and 44.83% respectively (p-value = 0.026). CONCLUSIONS: Macroscopic ENE (>2 mm) in oral cavity squamous cell cancer represents an aggressive entity with early regional and distant failure as compared to microscopic ENE (≤2 mm). Thus, macroscopic ENE (>2 mm) warrants a distinct subgroup with special consideration for intensification of treatment. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:588-593, 2023.

Effectiveness of Head-and-Neck Molecular Imaging Reporting and Data System Criterion in Head-and-Neck Squamous Cell Carcinoma PostConcurrent Chemoradiotherapy.

Purpose: Postconcurrent chemoradiotherapy (CRT) response assessment has been challenging in locally advanced head-and-neck squamous cell carcinoma (LA-HNSCC) due to prevailing postradiation changes. Molecular response methods have been encouraging, although further clarifications and validations were needed. We tested the effectiveness of a proposed semi-quantitative molecular response criterion in these patients. Materials and Methods: Two subspecialty-trained physicians evaluated 18F-fluorodeoxyglucose positron emission tomography/computed tomography of LA-HNSCC patients (n = 83) post 3 months CRT using a five points Head and Neck Molecular Imaging-Reporting and Data System (HAN-MI-RADS) criterion. Where available, histopathology examination with clinical and imaging interpretation was taken as a reference for the disease. A diagnostic accuracy comparison was done with the existing Hopkins score. Further effectiveness was analyzed with disease-free survival (DFI) and overall survival (OS). Results: Metastasis was developed in 11/83 patients at 3 months of evaluation. Of 72 patients, 39, 2, and 31 patients had a complete response, equivocal response, and partial response as per HAN-MI-RADS. Per patient sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for predicting loco-regional disease up to 1 and 2 years was 93.3%, 92.5%, 90.3%, 94.9%, 92.9%, and 84.9%, 91.9%, 90.3%, 87.2%, and 88.6% respectively. One year and two years DFI for each HAN-MI-RADS score showed a statistically significant difference while it was not for OS. The receiver operating characteristic curve analysis showed significantly better outcome predictability of HAN-MI-RADS (area under the curve [AUC] 0.884) than Hopkins (AUC 0.699). Conclusions: A five points HAN-MI-RADS criterion was found promising for response assessment with less equivocal results and statistically significant higher AUC than Hopkins for loco-regional recurrence prediction.

First report of mandibular ramus fracture associated with anterior dislocation of ipsilateral condyle into temporal fossa and locked jaw: A Rarity.

Mandibular ramus fracture is the second least common variant of fracture of mandible. Recently there has been an upsurge in the incidence of ramus fracture due to high velocity road traffic accidents. Ramus fracture is mostly seen in association with other mandibular fracture. This is the first report of mandibular ramus fracture associated with anterior dislocation of ipsilateral condyle into temporal fossa which was treated successfully under local anaesthesia by closed reduction.

Experience with Resorbable Plates for Fixation of Mandible Fracture. A Prospective Study of 10 Cases.

Aim: This study aims to evaluate the efficacy of resorbable plates for the fixation of mandible fracture. Materials and Methods: 10 cases of fracture mandible were treated with resorbable plates using the Inion CPS system. Patients were evaluated during their entire hospital stay and recalled on 1st, 4th, and 8th postoperative weeks. A thorough evaluation was done at the recall visits for any surgical and postoperative complications such as infection, malocclusion, neural abnormalities, wound or suture dehiscence, segmental mobility, foreign body reaction, and pain on biting. Bite force measurements were taken to evaluate the return of function. Results: Clinical union of the fracture was noted at the 8th week follow-up examination for all cases. There were swelling and pain at the operated site at 8th week follow-up for one patient, which was managed conservatively. The mean bite force was recorded for different regions and it increased over the entire follow-up period progressively. Conclusion: These plates and screws are an essential tool in the treatment of mandibular fractures owing to benefits such as biodegradability, biocompatibility, and the ability to be eliminated via the body's natural processes.

Intrathyroidal Plasmacytoma with Pleomorphic Multilobated Bizarre Cells: A Rare Primary Clinicopathological Presentation Mimicking Anaplastic Carcinoma of Thyroid.

BACKGROUND: Plasmacytoma involving thyroid gland is infrequent and can present as either primary extramedullary plasmacytoma or secondary to multiple myeloma. METHODS AND RESULTS: We present a case of 71 years old male who complained of a huge anterior neck swelling accompanied by dysphagia and dyspnoea. Fine needle aspiration cytology was suggestive of anaplastic carcinoma of thyroid (ATC), however, the subsequent histomorphology supported by immunohistochemistry (IHC) astoundingly favoured the diagnosis of plasmacytoma. Further evaluation revealed the presence of lymphadenopathy and single bone lesion in the present case which was rather suggestive of secondary involvement of thyroid to multiple myeloma. However, the case was unique in view of its presentation as a rapidly enlarging thyroid mass associated with stridor and cytomorphological findings which were of an undifferentiated malignancy favouring ATC. The use of a broad and judicious IHC panel clinched the final diagnosis of plasmacytoma. CONCLUSION: The present case emphasizes the diligent use of IHC in such cases given different therapeutic and prognostic implications.

A machine learning application for raising WASH awareness in the times of COVID-19 pandemic.

The COVID-19 pandemic has revealed the power of internet disinformation in influencing global health. The deluge of information travels faster than the epidemic itself and is a threat to the health of millions across the globe. Health apps need to leverage machine learning for delivering the right information while constantly learning misinformation trends and deliver these effectively in vernacular languages in order to combat the infodemic at the grassroot levels in the general public. Our application, WashKaro, is a multi-pronged intervention that uses conversational Artificial Intelligence (AI), machine translation, and natural language processing to combat misinformation (NLP). WashKaro uses AI to provide accurate information matched against WHO recommendations and delivered in an understandable format in local languages. The primary aim of this study was to assess the use of neural models for text summarization and machine learning for delivering WHO matched COVID-19 information to mitigate the misinfodemic. The secondary aim of this study was to develop a symptom assessment tool and segmentation insights for improving the delivery of information. A total of 5026 people downloaded the app during the study window; among those, 1545 were actively engaged users. Our study shows that 3.4 times more females engaged with the App in Hindi as compared to males, the relevance of AI-filtered news content doubled within 45 days of continuous machine learning, and the prudence of integrated AI chatbot "Satya" increased thus proving the usefulness of a mHealth platform to mitigate health misinformation. We conclude that a machine learning application delivering bite-sized vernacular audios and conversational AI is a practical approach to mitigate health misinformation.

Adamantinoma-like Ewing Sarcoma of the Nasal Cavity: A Rare Clinical Presentation with Deceptive Histopathologic Features.

Ewing sarcoma (ES) is a malignant round cell tumour (MRCT) that usually involves bone and soft tissue of young and paediatric populations. ES of the head and neck region is uncommon. Adamantinoma-like Ewing sarcoma (ALES) is a rare variant of ES that shows complex epithelial differentiation on histopathology and immunohistochemistry (IHC). It demonstrates a t(11;22) translocation and EWSR1- FLI1 fusion. Most documented cases of ALES of the head and neck region were initially misdiagnosed as epithelial tumours. We present a rare case of ALES of the nasal cavity in a young female. The patient subsequently underwent chemotherapy and showed an excellent response. Awareness of this entity is important for pathologists and oncologists due to its distinct therapeutic and prognostic implications. We propose performing upfront NKX2.2 and CD99 IHC studies, as well as other lineage specific IHC markers, in any poorly differentiated MRCT of head and neck region.

Patient Experience of a Neurology Tele-Follow-Up Program Initiated During the Coronavirus Disease 2019 Pandemic: A Questionnaire-Based Study.

Background: Teleneurology consultations can be highly advantageous since neurological diseases and disabilities often limit patient's access to health care, particularly in a setting where they need to travel long distances for specialty consults. Patient satisfaction is an important outcome assessing success of a telemedicine program. Materials and Methods: A cross-sectional study was conducted to determine satisfaction and perception of patients toward an audio call based teleneurology follow-up initiated during the coronavirus disease 2019 pandemic. Primary outcomes were satisfaction to tele-consult, and proportion of patients preferring telemedicine for future follow-up. Results: A total of 261 patients who received tele-consult were enrolled. Satisfaction was highest for domain technological quality, followed by patient-physician dialogue (PPD) and least to quality of care (QoC). Median (interquartile range) patient satisfaction on a 5-point Likert scale was 4 (3-5). Eighty-five (32.6%; 95% confidence interval 26.9-38.6%) patients preferred telemedicine for future follow-up. Higher overall satisfaction was associated with health condition being stable/better, change in treatment advised on tele-consult, diagnosis not requiring follow-up examination, higher scores on domains QoC and PPD (p < 0.05). Future preference for telemedicine was associated with patient him-/herself consulting with doctor, less duration of follow-up, higher overall satisfaction, and higher scores on domain QoC (p < 0.05). On thematic analysis, telemedicine was found convenient, reduced expenditure, and had better physician attention; in-person visits were comprehensive, had better patient-physician relationship, and better communication. Discussion: Patient satisfaction was lower in our study than what has been observed earlier, which may be explained by the primitive nature of our platform. Several variables related to the patients' disease process have an effect on patient satisfaction. Conclusion: Development of robust, structured platforms is necessary to fully utilize the potential of telemedicine in developing countries.

Transmission dynamics of the COVID-19 epidemic in India and modeling optimal lockdown exit strategies.

India imposed one of the world's strictest population-wide lockdowns on March 25, 2020 for COVID-19. We estimated epidemiological parameters, evaluated the effect of control measures on the epidemic in India, and explored strategies to exit lockdown. We obtained patient-level data to estimate the delay from onset to confirmation and the asymptomatic proportion. We estimated the basic and time-varying reproduction number (R0 and Rt) after adjusting for imported cases and delay to confirmation using incidence data from March 4 to April 25, 2020. Using a SEIR-QDPA model, we simulated lockdown relaxation scenarios and increased testing to evaluate lockdown exit strategies. R0 for India was estimated to be 2·08, and the Rt decreased from 1·67 on March 30 to 1·16 on April 22. We observed that the delay from the date of lockdown relaxation to the start of the second wave increases as lockdown is extended farther after the first wave peak-this delay is longer if lockdown is relaxed gradually. Aggressive measures such as lockdowns may be inherently enough to suppress an outbreak; however, other measures need to be scaled up as lockdowns are relaxed. Lower levels of social distancing when coupled with a testing ramp-up could achieve similar outbreak control as an aggressive social distancing regime where testing was not increased.

Modified submental platysmal adipomyofascial flap: is it a reliable alternate reconstructive option for small- to mid-sized defects especially in male patients with oral/oropharyngeal cancer?

PURPOSE: To introduce modified submental platysmal adipomyofascial flap as a new and viable hairless locoregional option for reconstruction of small- to mid-sized defects after ablative surgery in oral/oropharyngeal cancer patients keeping in mind the present pandemic situation. METHODS: An observational retrospective study was conducted using modified submental platysmal adipomyofascial flap as a locoregional reconstructive option for both intraoral and oropharyngeal defects in early-stage oral/oropharyngeal cancer patients, from Jan 2016 to May 2020 in a tertiary care hospital. All patients in this study were male and the overall flap outcome was evaluated with post-operative follow-up. RESULTS: Out of 18 patients, in 4 patients modified submental platysmal adipomyofascial flap was used as a combination of flaps for reconstruction. Six patients (33.33%) underwent adjuvant radiation therapy/radiation chemotherapy. The long-term functions (speech and swallowing) and cosmetic outcomes were good in the majority of the patients. One patient (5.55%) had pinhole oroantral fistula. No patient had any major flap failure. CONCLUSION: Modified submental platysmal adipomyofascial flap can be considered as a good alternative in male patients for reconstruction of small- to mid-sized oral cavity/oropharyngeal defects post-resection, especially during the prevailing pandemic crisis. It is an oncologically safe procedure with the major advantage of providing a hairless flap for oral cavity, tonsillar and BOT resection defects with lesser donor site morbidity.

SARS-CoV-2 epidemic in India: epidemiological features and in silico analysis of the effect of interventions.

Background: After SARS-CoV-2 set foot in India, the Government took a number of steps to limit the spread of the virus in the country. This included restricted testing, isolation, contact tracing and quarantine, and enforcement of a nation-wide lockdown starting 25 March 2020. The objectives of this study were to i) describe the age, gender distribution, and mortality among COVID-19 patients identified till 14 April 2020 and predict the range of contact rate; and ii) predict the number of  COVID-19 infections after 40 days of lockdown. Methods: We used a cross-sectional descriptive design for the first objective and a susceptible-infected-removed model for in silico predictions. We collected data from government-controlled and crowdsourced websites. Results: Studying age and gender parameters of 1161 Indian COVID-19 patients, the median age was 38 years (IQR, 27-52) with 20-39 year-old males being the most affected group. The number of affected patients were 854 (73.6%) men and 307 (26.4%) women. If the current contact rate continues (0.25-27), India may have 110460 to 220575 infected persons at the end of 40 days lockdown. Conclusion: The disease is majorly affecting a younger age group in India. Interventions have been helpful in preventing the worst-case scenario in India but will be unable to prevent the spike in the number of cases.

Utility and relevance of modified lateral trapezius myocutaneous flap as a locoregional reconstructive option for medium-sized ablative defects in head and neck cancer-our experience.

PURPOSE: Lateral trapezius myocutaneous (LTMC) flap has been used less frequently for defects pertaining to head and neck cancer ablative surgical defects. This study is to assess the utility of LTMC flap with a new modification of the flap design. METHODS: This is a retrospective study using LTMC flap with modifications as a reconstructive option for intraoral & extraoral skin defects in head and neck cancer patients following ablative surgery, from August 2014 to October 2019 in a tertiary care hospital. The original technique of LTMC flap was modified for better results and outcomes. RESULTS: Thirty-five patients underwent lateral trapezius flap reconstruction for ablative defects of oral cavity, laryngopharynx, neck and parotid. Twenty-three patients (65.71%) underwent adjuvant radiation/radiation-chemotherapy while one patient defaulted. Two patients (5.71%) had major flap failure. After the loss of flap in these patients, the operative technique was further modified for better results. However, the disadvantage of using this flap is shoulder disability. Nonetheless in the present study, the disability was reduced after modifying the operating technique by preserving the spinal accessory nerve. CONCLUSION: The present study demonstrated minimal functional loss, low morbidity with satisfactory results, thus also reducing treatment cost. Thus, LTMC is a reliable reconstructive option in head and neck cancer patients for medium-sized defects.

Infrahyoid flap revisited - A head and neck surgical perspective in the Indian setting.

PURPOSE: In India, head and neck cancer contributes to about 35% of all malignancies. Among head and neck squamous cell cancers, buccal mucosa and tongue are the most common subsites. Reconstruction of defects after resection of primary in these subsites with acceptable cosmetic and functional outcomes remains a challenging task. In the era of free flaps, many pedicled flaps are being overlooked. Infrahyoid flap (IHF) is one among them. This study discusses the feasibility of IHF in reconstruction of small and medium-sized defects in subsites of the oral cavity. MATERIALS AND METHODS: This study is a retrospective analysis of 23 patients who underwent IHF and reconstruction after excision of primary in a case of oral cavity squamous cell carcinoma from January 2010 till November 2017 with a median follow-up of 15 months. Patients who were diagnosed as a case of squamous cell carcinoma in oral cavity subsites (T1-T3 and N0/N1-N2) and in whom the anticipated defect size was small to medium were included. The evaluation was then done based on the possibility to reach recipient site, vitality after transposition, definitive integration, and clinical outcome. RESULTS: Out of 23 patients, 5 patients had flap-related complications of which 1 patient had total skin paddle necrosis and 4 patients had partial skin paddle necrosis at distal end. However, no patient developed oro-cutaneous fistula or required corrective surgery. The maximum flap dimension was 9 × 4 cm and average flap dimension was 6 × 4 cm. The postoperative outcome of all patients remained uneventful. CONCLUSION: The infrahyoid myocutaneous flap is a reliable and convenient flap which can be used as a good alternative for free flaps in small and medium-sized defects of the oral cavity.

Hydroxychloroquine as a Chemoprophylactic Agent for COVID-19: A Clinico-Pharmacological Review.

Hydroxychloroquine has gained much attention as one of the candidate drugs that can be repurposed as a prophylactic agent against SARS-CoV-2, the agent responsible for the COVID-19 pandemic. Due to high transmissibility and presence of asymptomatic carriers and presymptomatic transmission, there is need for a chemoprophylactic agent to protect the high-risk population. In this review, we dissect the currently available evidence on hydroxychloroquine prophylaxis from a clinical and pharmacological point of view. In vitro studies on Vero cells show that hydroxychloroquine effectively inhibits SARS-CoV-2 by affecting viral entry and viral transport via endolysosomes. However, this efficacy has failed to replicate in in vivo animal models as well as in most clinical observational studies and clinical trials assessing pre-exposure prophylaxis and postexposure prophylaxis in healthcare workers. An analysis of the pharmacology of HCQ in COVID-19 reveals certain possible reasons for this failure-a pharmacokinetic failure due to failure to achieve adequate drug concentration at the target site and attenuation of its inhibitory effect due to the presence of TMPRSS2 in airway epithelial cells. Currently, many clinical trials on HCQ prophylaxis in HCW are ongoing; these factors should be taken into account. Using higher doses of HCQ for prophylaxis is likely to be associated with increased safety concerns; thus, it may be worthwhile to focus on other possible interventions.

SYNGAP1 mutations: Clinical, genetic, and pathophysiological features.

SYNGAP1 is a gene that encodes the cytosolic protein SYNGAP1 (SYNaptic GTPase Activating Protein), an essential component of the postsynaptic density at excitatory glutamatergic neurons. SYNGAP1 plays critical roles in synaptic development, structure, function, and plasticity. Mutations in SYNGAP1 result in a neurodevelopmental disorder termed Mental retardation-type 5 (MRD5, OMIM #612621) with a phenotype consisting of intellectual disability, motor impairments, and epilepsy, attesting to the importance of this protein for normal brain development. Here we review the clinical and pathophysiological aspects of SYNGAP1 mutations with a focus on their effect on synaptogenesis, neural circuit function, and cellular plasticity. We conclude by comparing the molecular pathogenesis of SYNGAP1 mutations with those of another neurodevelopmental disorder that affects dendritic function and cellular plasticity, fragile X syndrome. Insights into the molecular similarities and differences underlying these disorders could lead to rationale therapy development.

Value of diffusion MR imaging in differentiation of recurrent head and neck malignancies from post treatment changes.

PURPOSE: Role of diffusion-weighted (DW) MR imaging in differentiating residual or recurrent neck malignancies from postoperative/post-radiation changes with histopathological correlation and comparison with PET-CT. METHODS AND MATERIALS: Prospective observational study for a period of 1 year in 62 post-radiation/post-operative patients suspected to have residual/recurrent tumors of neck with lesion diameter more than 5 mm measured on MRI. RESULTS: Mean ADC for recurrent/residual tumors: 1.008 ±â€¯0.220 × 10-3 mm2/s - significantly lower than mean ADC value for post-treatment changes of 1.69 ±â€¯0.40 × 10-3 mm2/s (p < 0.0001). The overall diagnostic accuracy, positive predictive value (PPV) and negative predictive value (NPV) of the qualitative assessment for the use of DWI in differentiating tumors recurrence from post-treatment changes were 96.6%, 96% and 83.3%, respectively. Upon quantitative analysis of the DW imaging data, a threshold ADC value of 1.3 × 10-3 mm2/s used for differentiating between post-treatment changes and recurrent cancers showed the highest combined sensitivity of 94%, specificity of 83.3%, accuracy of 93.6%, positive predictive value of 95.9%, and negative predictive value of 83.3%. CONCLUSION: DW MRI is a promising non-invasive MRI technique used to differentiate recurrent/residual head and neck malignancies from posttreatment changes based on ADC values. DWI offers advantage as it has a short scanning time and can be safely added to standard MRI protocol with minimum patient discomfort. Complementary use of DWI and PET/CT imaging may increase diagnostic confidence for differentiating recurrent disease from radiation therapy-induced changes after 6-12 months in posttreatment cases.