Office Rigid Laryngoscopy as a Predictor for Glottic Exposure in Microlaryngoscopy.

Good glottic exposure is a prerequisite for a good microlaryngeal surgery. Often this is difficult to predict preoperatively. This study aims to evaluate the utility of office-based rigid laryngoscopy (70°) as a screening tool to predict laryngeal exposure during micro laryngoscopy. Sixty-nine patients underwent office-based rigid laryngeal examination followed by micro laryngoscopic surgery for benign vocal cord lesions. Office-based laryngoscopy was classified as grade 1 when the entire glottis with anterior commissure (AC) was visualized without undue traction of tongue; grade 2 when AC was visualized only during phonation and with some traction of tongue and grade 3 when there is an inability to visualise the glottis adequately despite moderate traction of tongue and the examination was completed using a flexible scope. These were correlated with laryngeal exposure during micro laryngoscopy. 42 patients were categorized as grade 1 out of which 39 (93%) had a favourable laryngeal exposure (class 1) while only 3 (7%) had a partially favourable exposure (class 2). 18 patients were categorized as grade 2 out of which 12(66%) had a favourable exposure (class 1) as against 6 (33%) who had a partially favourable exposure (class 2). Nine of our patients were categorized as grade 3 out of which all 9 (100%) had an unfavourable exposure (class 3) requiring angled tele laryngoscopy to complete the surgery. A strong correlation between office-based laryngoscopic grading and exposure during operative laryngoscopy was obtained statistically (Cramer's V test, V = 0.746). Office examination with a 70° telescope is a good predictor of glottic exposure during micro laryngoscopy. We believe that the ease of performing a micro laryngoscopy in the operating room is directly proportional to the ease of doing laryngoscopy in the office.

Nail Society of India Recommendations for Treatment of Onychomycosis in Special Population Groups.

Onychomycosis (OM) is a difficult-to-treat condition, especially considering the limited armamentarium of antifungal drugs, need for prolonged treatment, and poor compliance. This problem is further confounded while treating OM in special populations such as children, elderly, immunosuppressed patients, pregnant or lactating women, and patients with chronic liver or kidney disease. In the absence of standardized treatment guidelines, the antifungal therapy is either withheld or compromised, as it is largely governed by personal preferences or based on anecdotal reports. Hence, an expert group of the Nail Society of India worked towards drafting guidelines based on established literature and inputs from experts, with practical recommendations for the treatment of onychomycosis in special population groups. An extensive analysis of available English language literature on onychomycosis in special populations, published during a 10-year period (2014-2023 until date) was done. The available studies and reports were evaluated, cross-references read, and evidence compiled, graded, and discussed by the expert group to derive consensus recommendations for practice. The evidence and recommendations based on it are presented in a narrative format to guide treatment choices when dealing with population groups with special considerations.

A Study of Community-Acquired Pyodermas with Special Reference to Panton-Valentine Leukocidin (PVL)-Positive Methicillin-Resistant Staphylococcus Aureus.

Background: Community-acquired (CA) pyodermas are one of the most common infections encountered in the dermatology outpatient clinics. A significant number of these conditions are caused by Staphylococcus aureus. CA-methicillin-sensitive Staphylococcus aureus (MSSA) and CA-methicillin-resistant Staphylococcus aureus (MRSA) have specific virulence genes which are associated with these diseases, particularly the Panton-Valentine leukocidin (PVL) genes. The presence of the PVL gene as a virulence factor may be associated with recurrent and severe skin infections. Materials and Methods: A prospective study was conducted with 205 cases of CA pyodermas, of which five were discarded due to mixed isolates. Clinical details were taken and wound exudate was sent for bacteriological examination. Further, the molecular study was performed on all MRSA (7) isolates and 13 randomly selected MSSA isolates using polymerase chain reaction for mecA and PVL genes. Results: Staphylococcus aureus was the most common organism (90%) isolated from primary or secondary CA pyodermas. The prevalence of CA-MRSA among all pyodermas was 3.5% in our community. The PVL gene was not detected in all tested CA-MRSA and CA-MSSA isolates. Conclusion: While pyodermas are common, the prevalence of MRSA is low in the CA pyodermas in our region. PVL does not appear to be a virulence factor among the isolated MRSA. Larger, multicentric, and periodic studies are, however, required to further justify these claims.

IADVL SIG Recalcitrant Dermatophytosis Position Statement on Super Bioavailable Itraconazole.

Itraconazole (ITZ) has been the mainstay of oral antifungal treatment for the current epidemic of recalcitrant dermatophytosis (RD) in India. Recently, a newer formulation of ITZ, super bioavailable itraconazole (SUBA-ITZ), is made available in the market by many pharmaceutical companies. It is important for dermatologists to understand the pharmacokinetic properties of SUBA-ITZ vis-a-vis conventional pellet formulation to use it effectively and safely. Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) has established a special interest group for recalcitrant dermatophytosis (SIG-RD) to strengthen research, continuing medical education, and industry collaboration on the subject. This position statement on SUBA-ITZ by SIG-RD is an attempt to address current pieces of evidence and the position of this new formulation in the management of RD.

Uncommon presentation of granulomatosis with polyangiitis: Prostate involvement.

Granulomatosis with polyangiitis (GPA) is an autoimmune granulomatous disease of unknown etiology; frequently associated with anti-proteinase 3 antineutrophil cytoplasmic antibody (PR3-ANCA). Although any organ can be involved, prostatic involvement in GPA is very rare. We present a male patient with GPA, 26 years old, with pulmonary manifestations and prostatic involvement who underwent exhaustive evaluation. The patient's laboratory tests and imaging scans showed evidence of lesions in multiple areas, including the prostate. Histopathological testing confirmed that the lesions were consistent with granulomatosis with polyangiitis. The patient was treated with oral steroids and rituximab and showed significant improvement. He was later maintained on azathioprine without any relapse.

Chromoblastomycosis: A Case Series and Literature Review.

Chromoblastomycosis is a subcutaneous mycosis caused by a variety of dematiaceous fungi. Fonsecaea (F.) pedrosoi is the most common causative agent. Majority of cases have been reported from tropical and subtropical regions with rural and agricultural background. It is a chronic disease with low incidence of complications but is very refractory to therapies. This is a case series of 22 cases of chromoblastomycosis from two health-care facilities in India. Information regarding the history, clinical presentations, diagnostic methods, therapy, and outcome of treatment were retrieved. Preponderance was seen among the males and in the age group of 41-60 years. Manual and agricultural laborers were commonly affected. Lower extremities were the most common sites affected. Morphological patterns like verrucous plaque, psoriasiform plaque, and verrucous nodules were seen. Direct microscopy with potassium hydroxide (KOH) mount was positive in all the cases. Histopathology in all cases displayed suppurative granulomatous inflammation with pigmented fungal cells. Fungal culture was positive in 10 cases with F. pedrosoi being the commonest agent. Antifungal treatment alone was instituted in 10 cases, cryotherapy along with antifungal therapy was given in 9 cases, and surgical excision was done in 3 cases. Complete clinical cure was achieved in seven cases. Chromoblastomycosis is characterized by chronicity, diverse clinical presentations, and therapeutic recalcitrance. Direct KOH mount of the black dots forms an important bedside tool in the diagnosis. Long-term antifungal therapy along with adjuvant cryotherapy may be the best option for the management.

Efficacy of Super-Bioavailable Itraconazole and Conventional Itraconazole at Different Dosing Regimens in Glabrous Tinea Infection - A Randomized Clinical Trial.

Introduction: Itraconazole follows non-linear pharmacokinetics and hence is recommended once daily, but in real-world practice, is commonly prescribed as twice daily. Hence, this study aimed to evaluate the efficacy and safety of super-bioavailable-itraconazole-130 mg (SB-130) and conventional-itraconazole-200 mg (CITZ-200) once daily compared with conventional-itraconazole-100 mg (CITZ-100) twice daily in glabrous tinea. Methods: A total of 261 eligible patients were enrolled in this prospective, randomized, clinical study from December-2021 to August-2022 at seven centers in India. Efficacy and safety assessments were done at week-3 and 6, with follow-up at week-10 for relapse. The primary objective was to assess the proportion of patients who achieved complete cure at week-6 following treatment in all itraconazole groups. The secondary outcomes were safety and clinical and mycological cure rates. Results: Of 261 patients, 240 were included in the analysis. At week-6, 140 patients were completely cured; thus, overall cure rate was 58.33%. Fifty-five patients (69%) in SB-130 while 47/77 (61%) and 38/83 (46%) patients were completely cured in CITZ-200 and CITZ-100 groups respectively (p<0.05; SB-130: CITZ-100, p=0.32; SB-130: CITZ-200, p=0.058; CITZ-200: CITZ-100). There was no statistical difference in the mycological cure rate and area clearance rate between any of the groups (p=0.14); however, a statistically significant difference was noted for OD dosing over BD dosing in achieving clinical cure rates (p<0.05). A total of 13/140 patients (9%) relapsed following complete cure, with no statistically significant difference between any of the groups (p=0.50). All treatments were safe and well-tolerated, with no discontinuation. Conclusion: In this clinical study, moderate efficacy with all doses of ITZ was reported but was better with OD dosing. Although there was no statistical difference between SB-130 and CITZ-200, SB-130 may be preferred over CITZ-200 owing to the advantage of SB over the conventional ITZ.

Idiopathic Ulcerative Laryngitis (IUL): An Indian Perspective.

Idiopathic ulcerative laryngitis (IUL) is characterized by bilateral ulceration of vocal cords which is followed by a protracted course of healing. It is rarely diagnosed, with a paucity of published data in English literature. There is no published data on this topic in the Indian population. Twenty-one patients from 3 centres were prospectively evaluated for clinical presentation, diagnosis, treatment, and follow-up. All patients underwent fibreoptic laryngoscopic evaluation and stroboscopic assessment. They were treated with supportive care and stringent follow-up. 21 patients with a median age of 39 years were included. This condition was commonly seen in males. All patients were treated conservatively except two who underwent a biopsy. The average time for full recovery in 14 of our patients who had compliant follow-ups was 9.24 weeks. GRBAS score improved from 9 to 5.93(p < 0.0001). Self-reported voice outcomes improved in all patients except for one patient who had a biopsy. IUL is uncommon but not rare in the Indian population. It shows full recovery with conservative management that involves at least more than 3-4 weeks.

Soil bacterial community structure and functioning in a long-term conservation agriculture experiment under semi-arid rainfed production system.

Soil microbial communities are important drivers of biogeochemical cycling of nutrients, organic matter decomposition, soil organic carbon, and Greenhouse gas emissions (GHGs: CO2, N2O, and CH4) and are influenced by crop and soil management practices. The knowledge on the impact of conservation agriculture (CA) on soil bacterial diversity, nutrient availability, and GHG emissions in semi-arid regions under rainfed conditions is vital to develop sustainable agricultural practices, but such information has not been systemically documented. Hence, studies were conducted for 10 years in rainfed pigeonpea (Cajanus cajan L.)-castor bean (Ricinus communis L.) cropping system under semi-arid conditions to assess the effects of tillage and crop residue levels on the soil bacterial diversity, enzyme activity (Dehydrogenase, urease, acid phosphatase, and alkaline phosphatase), GHG emissions, and soil available nutrients (Nitrogen, phosphorus, and potassium). Sequencing of soil DNA through Illumina HiSeq-based 16S rRNA amplicon sequencing technology has revealed that bacterial community responded to both tillage and residue levels. The relative abundance of Actinobacteria in terms of Operational Taxonomic Unit (OTUs) at phyla, class as well as genera level was higher in CA (NTR1: No Tillage + 10 cm anchored residue and NTR2 NT + 30 cm anchored residue) over CT (conventional tillage without crop residues). CA resulted in higher enzyme activities (dehydrogenase, urease, acid phosphatase, and alkaline phosphatase) and reduction in GHG emissions over CT. CA recorded 34% higher and 3% lower OC, as compared to CT, and CTR1, respectively. CA recorded 10, 34, and 26% higher available nitrogen, phosphorus, and potassium over CT and CTR1, respectively. NTR1 recorded 25 and 38% lower N2O emissions as compared to CTR1 and CTR2, respectively. Whereas only NT recorded 12% higher N2O emissions as compared to CT. Overall, the results of the study indicate that CA improves the relative abundance of soil bacterial communities, nutrient availability, and enzyme activities, and may help to contribute to the mitigation of climate change, and sustainability in rainfed areas.

Killian-Jamieson Diverticulum-A Rare Cause of Dysphagia in an Adult Male.

Killian Jamieson diverticulum is a rare diverticulum of the esophagus that out pouches through the Killian Jamieson's dehiscence. They are relatively rare compared to Zenker's diverticula, although both present similarly. However, both needs to be distinguished separately and treated accordingly given their anatomic variations.

COVID-19 Associated Mucormycosis (CAM): A Single Hospital-Based Study.

Background: Opportunistic fungal infections like Mucormycosis in Coronavirus Disease 2019 (COVID-19) patients have posed a great challenge to health care professionals, especially in developing countries like India. Hence, there is a need to understand the biological behaviour of COVID-19 associated Mucormycosis (CAM) to establish standard treatment Protocols and to reduce mortality. Aims: This study aims is to assess the type of Mucormycosis among COVID-19 patients in study population and compare the findings with clinical, radiological and haematological parameters along with treatment and surgical management. Methods and Material: This retrospective, observational study included 60 cases of CAM reported to the Department of Oral and Maxillofacial Surgery at the tertiary care centre, Karnataka Institute of Medical Sciences, Hubli. Data about various parameters were tabulated and analysed statistically. Statistical Analysis Used: Bivariate analysis was done using the Chi-Square test to assess the relationship between the type of Mucormycosis and other variables. Spearman's Correlation test was used to assess the correlation between types of Mucormycosis with the other variables. Linear regression analysis was performed to assess the response variable related to the type of Mucormycosis. Results: About 50% of subjects presented with "Rhino orbital" type of Mucormycosis. Palatal discoloration and palatal erosion was the most common oral manifestation among "only Sinus" and "Rhino orbital" types of Mucormycosis (P = 0.00). Significant association (P = 0.29) was found between the type of Diabetes mellitus and Mucormycosis. Conclusions: The study indicates that DM is the most commonly associated comorbidity in CAM patients. Hence, a thorough understanding of the underlying comorbidity and its close monitoring during and after COVID-19 infection is mandatory for successful treatment outcomes.

Relevance of Inflammatory Cytokine mRNA Expression of Tumour Necrosis Factor- Alpha (TNF α), Interleukin 17A (IL 17A) and Interleukin 6 (IL 6) in Indian Patients with Psoriasis.

Background: Psoriasis, a chronic, immune-mediated skin disorder, has systemic manifestations as well as an ample negative impact on the quality of life (QOL) of the patient. An abnormal proliferation of keratinocyte and dermal infiltration by immune cells is a characteristic feature. It involves components of both innate and adaptive immunity, and the interaction of T cells with macrophages. Keratinocytes and dendritic cells are mediated by the secreted cytokines. This study was taken up to look into changes at the molecular level that occur during the expression of three cytokines namely tumour necrosis factor-alpha (TNFα), interleukin 17A (IL-17A) and interleukin 6 (IL-6) in Indian patients with psoriasis. Methods: A case-control study was conducted with samples from 15 psoriasis vulgaris patients and 10 healthy control subjects. Clinical parameters were recorded. Blood samples were analysed for peripheral blood messenger ribonucleic acid (mRNA) expression of TNFα, IL-17A and IL-6 using real-time polymerase chain reaction (RT-PCR). Results: The mRNA expression of TNFα, IL-17A and IL-6 in psoriasis patients were increased as compared to that in normal subjects. Conclusions: The elevated levels of Interleukins indicates a systemic inflammatory process that is akin to the cutaneous inflammation. This study indicates that the targeted therapies against these cytokines are likely to be beneficial in Indian psoriasis patients.

A multicentric clinical and epidemiological study of chronic and recurrent dermatophytosis in India.

BACKGROUND: There has been an alarming increase in the prevalence of chronic, recurrent and steroid modified dermatophytosis of the glabrous skin in the recent years in India. There is paucity of literature on the magnitude of this major public health problem. OBJECTIVE: To estimate the prevalence of dermatophytosis and clinico-epidemiological features of chronic and recurrent dermatophytosis (CRD) across India and to evaluate the associated risk factors. METHODS: This is a multicentric descriptive cross-sectional study conducted in 13 centres situated across India in two phases during dry and rainy seasons. All consecutive patients presenting with dermatophytosis were screened during the study period of 14 consecutive working days. Patients with CRD of the glabrous skin as per the case definition were included after exclusion of isolated hair and nail infections. Demography, clinical findings and results of potassium hydroxide wet mount were recorded. RESULTS AND CONCLUSION: A total of 41,421 patients were screened, out of which 7174 (17.31%) patients had glabrous dermatophytosis. CRD was observed in 1999 (27.86%) patients with 78.08% and 21.95% of chronic and recurrent dermatophytosis, respectively. Family history was present in 50.03% of patients. History of sharing of fomites was present in 50.37% of them. Synthetic tight clothes were worn by 43.47%, while 50.9% gave history of misuse of topical corticosteroid creams. Multiple site involvement was common (69.58%) with tinea cruris (79.99%) and tinea corporis (75.69%) being the most common clinical types. CRD is associated with sharing of fomites, topical corticosteroid misuse and involvement of multiple sites.

Optimization and Validation of a Multiresidue Method for Screening of 126 Pesticide Residues in Herbal Raw Materials and Extracts Used as Ingredients in Ayurvedic Medicines and Dietary Supplements.

BACKGROUND: Testing for pesticide levels in herbal products is an important aspect in determining product safety. Plants and their extracts are widely used as ingredients in botanical dietary supplements and traditional medicines. The extracts of plants, especially those prepared out of organic solvents, are rich in secondary metabolites and pigments, and adequate clean-up is required since the extracts completely dissolve in organic solvents. OBJECTIVE: The study aims at reporting a multiresidue analytical method for 126 different pesticides in raw material biomass as well as extracts of plants, which are widely used as ingredients in ayurvedic medicines as well as dietary supplements using LC-MS/MS and GC-MS/MS with a rugged sample preparation technique for accurate results. METHOD: QuEChERS (quick, easy, cheap,effective, rugged, and safe) procedure, gel permeation chromatography (GPC), GPC coupled with solid phase extraction (SPE), and liquid-liquid extraction (LLE) coupled with SPE sample preparation methods were compared against each other for suitability to test pesticides in selected herbal raw materials and their alcoholic and aqueous extracts. The standard addition method was used for quantifying the level of pesticides below 10 µg/kg. RESULTS: Single laboratory validation for sample preparation involving GPC and SPE resulted linearity in the range of 2.5-500 ng/mL, average intraday and interday precision of 6.6% RSD, and average recovery (spiked at 10 µg/kg) of 92% for all analytes tested. The method was repeatable with different analysts and days. CONCLUSIONS: The sample preparation technique combining GPC and SPE as well as LLE and SPE was the most suitable for the selected herbal alcoholic extracts, whereas any of the regular techniques involving LLE, SPE, and QuEChERS were suitable for raw material biomass as well as aqueous extracts. HIGHLIGHTS: The method was found to be capable of determining selected pesticides in the selected matrixes at 10 µg/kg concentration. Provision of recycling solvents used in the GPC+SPE method was adopted to make the method environmentally friendly.

The Chondroma of Arytenoid Cartilage: A Case Report.

The chondromas of laryngeal cartilage constitute less than 1% of common mesenchymal tumors of the larynx. 70-75% of chondroma is located at the endolaryngeal surface of the cricoid cartilage. Here is a case report of the chondroma of arytenoid cartilage-a rare site of occurrence. A middle aged male patient, presented to the outpatient department of otorhinolaryngology with a history of hoarseness of voice. On Flexible laryngoscopy [Pentax, Tokyo, Japan], the right vocal cord was found to be immobile along with a smooth bulge noted over the arytenoid cartilage. The computerized tomography scan of the neck showed a well-defined peripherally calcified lesion arising from the superior aspect of right arytenoid cartilage possibly chondroma. Patient underwent microlaryngeal surgery and sub mucosal excision of the arytenoid mass which was confirmed as chondroma on histopathological examination. High degree of suspicion is required while examining a patient with hoarseness of voice and one should have chondroma as one of the differential diagnosis.

Onycho-mucocutaneous syndrome secondary to human immunodeficiency virus disease.

Cutaneous, mucosal, and nail examination is the key to unveiling a plethora of systemic diseases. Mucocutaneous lesions directly related to human immunodeficiency virus (HIV) infection usually present as initial manifestations of immune deficiency, of which few lesions act as predictors of an immunocompromised state. Here, we report two cases who presented with onycho-mucocutaneous symptoms which raised the suspicion of and invariably led to the diagnosis of an underlying immunosuppression secondary to HIV infection.