Radiological versus Traditional Parameters for Airway Assessment: A Comparison.

Background: The incidence of difficult tracheal intubation includes not only difficult and failed intubation but also difficult laryngoscopy (DL) and difficult mask ventilation. Aim: The study was done to compare the sonographic assessment of tongue thickness (TT) and condylar mobility with traditional airway assessment scores for prediction of difficult intubation (DI). Settings and Design: This experimental, randomized prospective study was conducted in the Department of Anaesthesia, Himalayan Institute of Medical Sciences, Dehradun. Materials and Methods: After obtaining approval from the Institutional Ethical and Research Committee, this study was conducted in the Department of Anaesthesiology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Swami Ram Nagar, Dehradun. After obtaining written and informed consent, 385 subjects of either sex between 18 and 60 years of age, undergoing various elective surgeries under general anesthesia with endotracheal intubation, were selected. The number of attempts at intubation, the need for alternative DI approaches, and invasive airway access or cancellation of the procedure due to inability to secure the airway were noted. Statistical Analysis Used: Data analysis was done using SPSS 20.0. Categorical data were assessed by Chi-square test, while independent t-test/Mann-Whitney test was used to determine the association between continuous data. Results: Age, inter-incisor distance (IID), body mass index (BMI), and Mallampati score were positively correlated with TT. BMI (kg.m-2) >26.0, modified Mallampati scoring >2, IID ≤5 cm, TT >6 cm, and condylar mobility >10 mm were significantly more among subjects with DL and difficult tracheal intubation. Conclusion: Ultrasonography can be used in elective settings to rule out any possibility of difficult airway and to prevent airway-related complications.

Frequency and Spectrum of Cutaneous Metastases of Visceral Malignancies: A Retrospective Observational Study of Three Years Duration in a Tertiary Care Hospital.

BACKGROUND: In spite of the skin being the largest organ of the body, cutaneous malignancies are uncommon especially in people of color as compared to the white population. The incidence of cutaneous metastases of visceral malignancies is further low and accounts for 0.5% to 10% of cancer cases as per written literature. Cutaneous metastasis as the presenting sign of underlying internal malignancy is extremely rare and is a marker of poor prognosis. Limited data is available in written literature about the frequency and spectrum of metastatic skin lesions in the Asian population. OBJECTIVE: 1) To find the frequency of metastasis of visceral malignancies in skin biopsies. 2) To evaluate the clinicopathological presentation and immunohistochemistry (IHC) profile of cutaneous metastases. SUBJECTS AND METHODS: It is a retrospective analysis of all the skin biopsies received in our department of Pathology for HPE from 01 Jan 2017 till 31 Dec 2019. Cases of cutaneous malignancy were segregated into primary and metastatic categories. Clinical details of the cases of cutaneous metastases were retrieved and analyzed. All the cases of cutaneous metastases were studied in detail for their clinical presentation, histomorphological features, and findings on IHC. RESULTS: Out of a total of 484 skin biopsies in 3 years, 9.7% showed features of malignancy. Total ten cases of cutaneous metastases (2%) were found, out of which three were the primary presentation of silent visceral malignancy. The lung, breast, colon, and ovary were the common primary sites to manifest as cutaneous metastases with the abdominal wall being the commonest site. Histomorphological features aided by the IHC panel helped in diagnosing the cutaneous metastases and site of the primary malignancy. CONCLUSION: Cutaneous metastasis as the primary presentation of visceral malignancy is rare and should not be missed as it indicates a poor prognosis. Clinico-pathological correlation and histomorphological features assisted by IHC markers help pathologists in diagnosing the site of primary malignancy in cases of cutaneous metastases.

A case series of unusual presentations of Burkitt's lymphoma.

CONTEXT: Burkitt's lymphoma (BL) is one of the fastest growing malignancies. It is the most common subtype of Non-Hodgkin's lymphoma in childhood. It has three major subtypes - endemic, sporadic, and immunodeficiency-associated types. AIMS: This study aims to study the clinicomorphologic features of this disease entity and to find optimal imaging technique for such cases. SETTING AND DESIGN: A retrospective observational study in a tertiary care center of academic and research potential. SUBJECTS AND METHODS: We are presenting three unusual cases of sporadic type of BL who presented initially as localized right iliac fossa mass mimicking as acute appendicitis. Initially, localized presentation progressed to diffuse abdominal mass lesions causing intestinal obstruction. RESULTS: These cases had emphasized the importance of accurate diagnosis by the ultrasonography (USG) or computed tomography (CT) scan for early diagnosis so as to manage such cases simply by early appropriate medical treatment. CONCLUSION: In this article, we will discuss the clinical and imaging features of BL with the role of USG, CT scan and positron emission tomography/CT in the abdominopelvic imaging of pediatric patients.

A study of therapy targeted EGFR/ALK mutations in Indian patients with lung adenocarcinoma: A clinical and epidemiological study.

BACKGROUND: Established predictive biomarkers for Non-Small Cell Lung Carcinoma (NSCLC) include sensitizing Epidermal Growth Factor Receptor (EGFR) mutations and Anaplastic Lymphoma Kinase (ALK) fusion oncogene. The primary aim of the study is to ascertain the prevalence of EGFR mutation and ALK gene rearrangement in patients of lung adenocarcinoma in Indian population and the second objective is to impress upon the importance of adequate processing of limited tissue samples. METHODS: Histopathologically confirmed cases of lung adenocarcinoma, whose tumour had been tested for both EGFR and ALK gene mutations, were included in this study. The EGFR mutations were analyzed using PCR and Gene Sequencing. ALK fusion oncogene was found by Fluorescence In Situ Hybridization (FISH) technique using kit of Vysis LSI ALK Dual colour Break Apart Rearrangement probe. RESULTS: A total of 152 cases of lung adenocarcinoma were included. Out of which, 92 (60.5%) were male and 60 (39.5%) were female. After exclusion of 17 cases due to unsatisfactory result, EGFR mutations were found positive in 35.5% cases (48/135). ALK gene rearrangement was found in 7.6% (10/131) after excluding 21 cases with unsatisfactory result. CONCLUSION: EGFR mutations and ALK gene rearrangement was found to be mutually exclusive. Incidence of EGFR mutations (35.5%) is much higher in Indian population than in Caucasians (13%) and is close to the incidence in East Asian countries. The 7.6% incidence of ALK fusion oncogene in Indian patients establishes the importance of molecular studies to give maximum benefit of targeted therapy to the patients.

Epithelioid osteoblastoma of maxilla: A rare and aggressive variant of a benign neoplasm at an uncommon site.

Osteoblastoma (OB) is an uncommon benign bone-forming tumor accounting for <1% of all bone neoplasms. Unlike conventional OB, its small subset variant "Epithelioid osteoblastoma (EO)" is characterized by its propensity for local invasion and recurrent behavior. This rare variant of an uncommon tumor when occurs in an atypical site can lead to diagnostic problems more so due to ambiguous clinico-radiologic presentation. This was what faced in the present case of 18-year-old female with a swelling in upper jaw. OB is usually more common in males and involves primarily the posterior element of the spine and the sacrum (40-55%). Less frequently, long bones of limbs are involved. Clinical, radiological and histopathological correlation in this case guided us to reach at right diagnosis of EO which helped the patient in getting correct treatment which involves surgical excision over conventional curettage. The purpose behind this case presentation is to improve the awareness about this recurrent tumor variant which has many close differentials including well-differentiated osteoblastic osteosarcoma.

A rare case of subungual melanoma.

A 51-year-old male presented with blackish discoloration of nails of 10 months duration. Examination revealed black dystrophic left thumb finger nail. Detailed examination showed a mass under the dystrophic nail. Hutchinson sign was positive. Histopathology revealed characteristic features of melanoma. A detailed evaluation revealed no features of local or distant metastasis. The entire lesion was then removed surgically along with disarticulation at the interphalangeal joint. Resection-free margin was confirmed. This case is being reported for the rare occurrence of subungual melanoma in the Indian population and also for presentation with a long history of lesion with no evidence of metastasis.

A case of disseminated superficial porokeratosis associated with giant porokeratosis in pregnancy.

A 23-year-old pregnant lady presented with dark raised lesions over face, axillae, and upper limbs of 15-day duration. She was 35 weeks pregnant at the time of onset of the lesions. Dermatological examination revealed hyperpigmented plaques on the face and papules with raised borders in the axillae and proximal arms. Skin biopsy from both the lesions revealed a diagnosis of porokeratosis. She was treated with emollients alone and the lesions regressed four weeks following delivery. This case is being reported for the rare occurrence of the combination of disseminated superficial porokeratosis with giant porokeratosis in pregnancy.

Comparison of SHF and SSF of wet exploded corn stover and loblolly pine using in-house enzymes produced from T. reesei RUT C30 and A. saccharolyticus.

The aim of the present study was to compare bioethanol production from wet exploded corn stover (WECS) and loblolly pine (WELP) hydrolyzed with in-house and commercial enzymes and fermented separately (SHF) and simultaneously (SSF). In-house enzymes produced from Trichoderma reesei, RUT-C30 and a novel fungal strain, Aspergillus saccharolyticus were loaded as 5 and 15 FPU/g glucan and supplemented with 10 and 30 CBU/g glucan, respectively. For hydrolysis and fermentation, slurries of WECS and WELP at 5 and 10% (w/w) solids loading (SL) were utilized. Saccharomyces cerevisae was used for ethanol fermentation at 33°C. Maximally, 15.6 g/L and 13.4 g/L (corresponding to theoretical ethanol yield of 76% and 67%, respectively) were achieved in SSF process from WECS and WELP, respectively at 5% SL and 15 FPU/g glucan loading of in-house enzymes. Ethanol concentrations in all cases were higher for SSF compared to SHF under same conditions. A cross comparison of SSF with commercial enzymes (Celluclast 1.5 L + Novozym 188) showed highest ethanol concentration of 17.3 g/L and 15.4 g/L (corresponding to theoretical ethanol yield of 84% and 77%, respectively) from WECS and WELP, respectively at 5% SL and 15 FPU/g glucan. These findings demonstrated that in-house enzymes were comparable to commercial enzymes as these fungi produced other lignocellulolytic enzymes beyond cellulase and hence enhanced the overall enzyme activity.

Primary primitive neuroectodermal tumor of kidney: a rare case report with diagnostic challenge.

Primary primitive neuroectodermal tumors (PNETs) of the kidney are quite rare and can be mistaken for a wide variety of other small round blue cell tumors which includes rhabdomyosarcoma, Wilm's tumor, carcinoid, neuroblastoma, clear cell sarcoma of the kidney, lymphoma etc. Renal Ewings/PNET can occur in the age group from 4 to 61 years. Approximately, 90% of Ewing sarcoma (ES)/PNET have a specific t(11;22) which results in a chimeric EWS-FLI-1 fusion protein. Immunohistochemical for the carboxy-terminus of FLI-1 is sensitive and highly specific for the diagnosis of ES/PNET. Herein, we have an interesting presentation in a 23-year-old male who came with neck pain and progressive quadriparesis and was diagnosed as a case of poorly differentiated malignant tumor with a differential of lymphoma versus metastatic renal cell carcinoma. The patient's condition deteriorated fast and he had a rapid downhill course. The final diagnosis of Ewings/PNET was confirmed at autopsy.

On-site enzymes produced from Trichoderma reesei RUT-C30 and Aspergillus saccharolyticus for hydrolysis of wet exploded corn stover and loblolly pine.

Cellulase production by two filamentous fungi Trichoderma reesei RUT-C30 and novel fungal strain, Aspergillus saccharolyticus on pretreated corn stover was investigated. Cellulase production was followed by the hydrolysis of two feedstocks, wet-exploded corn stover (WECS) and wet-exploded loblolly pine (WELP) by on-site produced enzyme cocktails containing cellulase from T. reesei RUT-C30 and ß-glucosidase from A. saccharolyticus. The sugar yields using the on-site enzyme cocktails were compared with commercial enzymes preparations, Celluclast 1.5L and Novozym 188 at two substrate concentrations, 5% and 10% (w/w) and enzyme loading at 5 and 15 FPU/g glucan for WECS and WELP. The highest sugar yields were obtained at 5% (w/w) substrate concentration and 15 FPU/g glucan for both feedstocks. Glucose yields of 81% and 88% were obtained from on-site and commercial enzymes, respectively using WECS as feed stock. The sugar yields were 55% and 58% for WELP samples hydrolyzed with on-site and commercial enzymes, respectively.

Producing high sugar concentrations from loblolly pine using wet explosion pretreatment.

We present quantitative analysis of pretreatment for obtaining high conversion and release of sugars from loblolly pine. We use wet explosion (WEx): wet oxidation followed by steam explosion and enzymatic hydrolysis (EH) at high dry matter to solubilize sugars. WEx was conducted at 25% (w/w) solids in presence of oxygen at pressures 6.5-7.2 bar, temperatures 170-175°C and residence time from 20 to 22.5 min. EH of pretreated samples was performed by Cellic® Ctec2 (60 mg protein/g cellulose) and Cellic® Htec2 enzymes (10% of Ctec2) at 50°C for 72 h. At the optimal WEx condition 96% cellulose and nearly 100% hemicellulose yield were obtained. The final concentrations of monomeric sugars were 152 g/L of glucose, 67 g/L of xylose, and 67 g/L of minor sugars (galactose, arabinose and mannose). Compared to previous work WEx seems to be superior for releasing high concentrations of monomeric sugars.

Bilateral benign non functional struma ovarii with Pseudo-Meigs' syndrome.

Bilateral presentation of benign Struma ovarii is rare and has not been reported frequently in published literature. A 70-year-old postmenopausal female presented with progressive ascites, bilateral pleural effusion and elevated CA-125 levels. The contrast-enhanced computed tomography (CECT) of the abdomen and pelvis revealed a heterogenous mass in the left adnexa. These findings were suspicious for an ovarian malignancy. After surgery the diagnosis of non functional, bilateral benign Struma ovarii was made. Struma ovarii is a specialized ovarian teratoma composed predominantly of mature thyroid tissue. It is associated with pleural effusion and ascites (Pseudo-Meigs' syndrome) in 5% of cases. The combination of struma ovarii and elevated CA-125 levels has been reported infrequently. This is a rare case of bilateral benign struma ovarii associated with Pseudo-Meigs' syndrome and elevated CA-125 levels. Surgical excision of the ovarian masses induced immediate resolution of the ascites and pleural effusion and a reduction of the serum CA-125 level.