Double outlet right ventricle, pulmonary stenosis and congenital mitral stenosis.

A 4-year-old girl child was diagnosed with double outlet right ventricle (DORV), severe pulmonary stenosis, and supramitral ring. This case is presented to bring to light this rare association. Through this report, we aim to stress importance of assessing mitral apparatus on echocardiography during evaluation for situations like DORV and Tetralogy of Fallot (TOF). The physiological differences in such situations as opposed to their isolated counterparts and special postoperative outcomes are also discussed.

Mobile phone app Vs bucket test as a subjective visual vertical test: a validation study.

BACKGROUND: The SVV tests the ability of a person to perceive the gravitational vertical. A tilt in SVV indicates vestibular imbalance in the roll plane, and thus injuries to the utricle or its connecting nerves. A validated bedside method (et, al., 2009, 72(19):1689-1692, Neurol, Zwergal) is the bucket method, in which the subject estimates the true vertical by attempting to properly align a straight line visible on the bottom of a bucket that is rotated at random by the examiner. In our study, the subjects need to align the plumb line on the Visual Vertical iOS app to the vertical direction. METHODS: Measurements of the SVV were made in 22 healthy subjects (16 females and 6 males). Each subject conducted 10 iterations of bucket test and 10 iterations of iOS app test. The reliability and validity of the iOS app was analyzed by SPSS21. RESULTS: Cronbach's α for the plumb line method was 0.976, and the iOS app was 0.978. Statistical comparison of SVV values measured by the iOS app and the bucket method showed no significant difference in distribution (Mann Whitney U test U = 0.944). CONCLUSION: The Visual Vertical iOS app is an effective and accessible substitute to the plumb line for the measurement of the validated bucket test.

The Benefit of a Wireless Contralateral Routing of Signals (CROS) Microphone in Unilateral Cochlear Implant Recipients.

OBJECTIVE: Assess speech outcomes in unilateral cochlear implant (CI) recipients after addition of a wireless contralateral routing of signals (CROS) microphone. STUDY DESIGN: Prospective cohort study. SETTING: Ambulatory. PATIENTS: Sixteen adult unilateral CI users with nonserviceable hearing on the contralateral side were recruited. Those with AzBio sentence scores of 40 to 80% or Hearing in Noise Test - Quiet (HINT-Q) scores of 60 to 90% with a CI alone were eligible participants. INTERVENTION: Speech testing was carried out with the CROS on and off. MAIN OUTCOME MEASURE: Speech recognition. RESULTS: In the consonant-nucleus-consonant test presented in quiet from the front, word scores were 64.4 (CI) and 63.8% (CI + CROS) (p = 0.72), and phoneme scores were 80.2 (CI) and 80.8% (CI + CROS) (p = 0.65). In AzBio sentence testing in quiet, with the signals projected from the contralateral, front, or ipsilateral to the CI, speech perception with the CI alone was 60.8, 75.9, and 79.1%. With the addition of the CROS microphone, using the same speaker arrangement, speech perception was 69.8 (p < 0.05), 71.8 (p = 0.05), and 71.8 (p < 0.05). In AzBio sentence testing in noise, speech perception with the CI alone was 18.6, 45.3, and 56.3% when signals were projected from contralateral, front, and ipsilateral sides to the CI. The addition of the CROS microphone led to speech perception of 45.3 (p < 0.05), 45.3 (p = 0.86), and 51.4% (p = 0.27) in the same paradigm. CONCLUSIONS: Addition of a wireless CROS microphone to a unilateral CI recipient can improve users' perception of speech in both quiet and noise if speech signals come from the deaf ear, mitigating the head shadow effect.

Reaching endpoints for lymphatic filariasis elimination- results from mass drug administration and nocturnal blood surveys, South Gujarat, India.

BACKGROUND: Following the World Health Assembly resolution on Elimination of lymphatic filariasis (ELF) as a public health problem by the year 2020, a Global Program (GPELF) was launched in 1997 to help endemic countries to initiate national programs. The current strategy to interrupt transmission of LF, is administration of once-yearly, single-dose, two-drug regimen (Albendazole with Diethylcarbamazine (DEC) to be used in endemic areas with the goal of reaching 65% epidemiological coverage for 4-6 years. We report findings of independent assessment from year 2010 to 2015 for last six rounds, after initial five rounds of Mass Drug Administration (MDA) since 2005 for ELF in endemic area of Gujarat. METHODS: Independent assessment of MDA was performed to find coverage and compliance indicators, reasons for non-coverage and non-compliance in five Implementation Units (IUs). Pre, during and post MDA evaluations were done in three phases. The impact of MDA was measured by microfilaraemia survey. A total of eight sites, four random and four fixed sentinel sites were selected to calculate microfilaria rate (MF) per IUs per year. In years 2010 to 2015, we report results from 125,936 nocturnal blood smears and 17551 population in 120 selected clusters. Four clusters were selected per year in each of the five IUs for assessment of MDA round. RESULT: Post MDA survey showed drug coverage between 81%-88% and epidemiological coverage 77%-89% across years. Main reasons for non-coverage were drug administrator related (the team did not visit or missed people) while non-compliance was population related (fear of side effects, sickness, people forgot or absent). During MDA findings show that the directly observed consumption is considerably improved from 58% in 2010 to 82% in 2015. The knowledge about benefits of drug provided also increased from 59% to 90% over the years. The current MF rate is less than one in all IUs with an overall 68% percent decrease from baseline year 2005 to year 2015. The average MF rate of Gujarat is 0.44 for year 2015. CONCLUSIONS: The findings show that achieving adequate epidemiological and drug coverage is possible by actual field level operation of the program in large endemic areas. The results and feedback from independent assessment, performed regularly, could guide the policymakers and program managers for mid-term corrections and to frame strategies to enhance program. Monitoring of coverage and impact indicator together informs decisions for reaching end-point of MDA. The impact indicator- microfilaria rate in all IUs of South Gujarat Region has reached and remained less than one percent signaling end-points of MDA. Post MDA stringent monitoring in form of TAS is recommended to keep vigil on maintenance of elimination achieved.

Chronic blepharitis like picture in patients with Discoid lupus erythematosis - Case series.

BACKGROUND: Blepharitis is a very common condition encountered in ophthalmology outpatient care department. Dermatological diseases like seborrheic keratopathy and rosacea have been frequently discussed as being associated with blepharitis. However Discoid lupus erythematosis [DLE], an autoimmune condition has only rarely been reported to involve the eyelids mimicking blepharitis. DLE affecting the eyelids can produce significant morbidity with lid deformities, trichiasis and symblepharon if left untreated. OBJECTIVE: To report three consecutive cases of DLE with eyelid lesions mimicking blepharitis. They presented to the department of ophthalmology at our institute from April 2014 to March 2016. The first case presented with involvement of lower eyelid in one eye. She was having multiple skin lesions which on biopsy confirmed the diagnosis of DLE. The second case was a diagnosed case of DLE who received treatment 4 years back and came with relapse of the disease affecting the eyelid. The third case was a recently biopsy confirmed case of DLE with multiple skin lesions along with bilateral eyelid involvement. Two of them had madarosis and one case had destruction of the outer lid margin at presentation. All three cases responded well to treatment with Hydrxychloroquin. CONCLUSION: The discoid lesions of DLE affecting the eyelids can mimic the appearance of chronic blepharitis. Ophthalmologists should be aware that DLE is a possibility while dealing with an atypical case of chronic blepharitis. Early diagnosis and treatment can prevent deformities of eyelid.

Methicillin-resistant Staphylococcus aureus colonization and disease severity in atopic dermatitis: a cross-sectional study from South India.

BACKGROUND: Colonization by methicillin-resistant Staphylococcus aureus (MRSA) in atopic dermatitis is little studied but has therapeutic implications. It may have a role in disease severity given the additional virulence factors associated. AIMS: Our aims were to record the proportion of patients with MRSA colonization in atopic dermatitis and to ascertain if any association exists between MRSA colonization and disease severity. METHODS: An observational cross-sectional study involving children aged≤12 years with atopic dermatitis attending the outpatient department of Government Medical College, Kottayam was conducted. Socio-demographic data, exacerbating factors and risk factors for hospital care-associated MRSA were documented. Extent of atopic dermatitis was recorded using a standardized scale (Eczema Area Severity Index, EASI). Skin swabs were taken from anterior nares and the worst affected atopic dermatitis sites for culture and sensitivity. RESULTS: Of the 119 subjects recruited during the study period (November 2009-April 2011), Staphylococcus aureus was isolated from 110 (92.4%) patients and MRSA from 30 (25.21%) patients. A total of 18 patients with MRSA had risk factors for healthcare associated-MRSA. The patients whose cultures grew MRSA were found to have significantly higher EASI score when compared to those patients colonized with methicillin sensitive Staphylococcus aureus (P < 0.01). Presence of Staphylococcus aureus, early age of onset, presence of food allergies, seasonal exacerbation and inadequate breastfeeding did not seem to influence disease severity. CONCLUSIONS: There is a high degree of prevalence of MRSA (25.2%) in atopic dermatitis and presence of MRSA is associated with increased disease severity. Further studies are needed to validate these findings.

Mastoidectomy and mastoid obliteration with autologous bone graft: a quality of life study.

BACKGROUND: A mastoid cavity resulting from a canal wall down mastoidectomy can result in major morbidity for patients due to chronic otorrhea and infection, difficulty with hearing aids and vertigo with temperature changes. Mastoid obliteration with reconstruction of the bony external ear canal recreates the normal anatomy to avoid such morbidity. Few have the studied the quality of life benefit that this procedure confers. METHODS: This retrospective observational study was conducted to determine if mastoid obliteration with autologous cranial bone graft following mastoidectomy improves quality of life (QOL). Patients with cholesteatoma who had mastoidectomy with primary or secondary mastoid obliteration by a tertiary otologist were surveyed using the validated Glasgow Benefit Inventory (GBI), our primary outcome measure. RESULTS: Fifty-eight patients were interviewed. Forty-six were primary obliteration after canal wall down mastoidectomy of a primary cholesteatoma. Twelve were secondary obliteration of an existing canal wall down mastoid cavity. Overall GBI scores were improved, with average scores of 22. Average general subscale scores were 23, physical health scores were 25, and social health scores were 22. The primary obliteration group had average scores of 19, general subscale scores of 20, physical health scores of 21, and social health scores of 22. Those with secondary obliteration scored higher, with average scores of 31, general subscale scores of 34, physical health scores of 39, and social health scores of 25. CONCLUSION: This study shows that mastoidectomy with obliteration using autologous cranial bone graft offers a significant QOL benefit. The GBI scores compare favourably with other otorhinolaryngology procedures. Secondary obliterations after revision mastoidectomy scored much higher than primary obliterations. This is currently the only QOL study comparing these two patient groups.

Low dose intravenous immunoglobulins and steroids in toxic epidermal necrolysis: a prospective comparative open-labelled study of 36 cases.

BACKGROUND: Toxic epidermal necrolysis (TEN) is a severe adverse drug reaction associated with high mortality. Though different modalities of treatment are advocated, there is no consensus regarding specific therapy. Corticosteroids have shown conflicting results and for high dose intravenous immunoglobulins (IVIG), cost is a limiting factor. AIM: To find out the effectiveness of combination therapy with low-dose IVIG and steroids versus steroids alone in our TEN patients. METHODS: After obtaining Ethical Committee approval, 36 consecutive TEN patients (2008-2012) were alternately allocated to 2 groups - Group A was given combination of low-dose IVIG (0.2-0.5 g/kg) and rapidly tapering course of steroids (intravenous dexamethasone 0.1- 0.3 mg/kg/day tapered in 1-2 weeks) while Group B was given same dose of steroids alone. Outcome parameters assessed were time taken for arrest of disease progression, time taken for re-epithelization, duration of hospital stay and mortality rates. RESULTS: Both groups had 18 patients. Baseline characteristics like age, sex ratio, SCORTEN, body surface area involvement and treatment interval were comparable. Time for arrest of disease progression and for re-epithelization was significantly lowered in Group A (P = 0.0001, P = 0.0009 respectively). Though duration of hospital stay and deaths were less in Group A, difference was not statistically significant. SCORTEN based standardized mortality ratio (SMR) analysis revealed that combination therapy reduced the probability of dying by 82% (SMR = 0.18 ± 0.36) and steroids by 37% (SMR = 0.63 ± 0.71). Difference in SMR was statistically significant (P = 0.00001). No significant side effects due to either modality were found in any of the patients. CONCLUSION: Combination therapy with low-dose IVIG and steroids is more effective in terms of reduced mortality and faster disease resolution when compared to steroids alone in TEN.

Surgical vs ultrasound-guided drainage of deep neck space abscesses: a randomized controlled trial: surgical vs ultrasound drainage.

INTRODUCTION: Deep neck space abscesses (DNAs) are relatively common otolaryngology-head and neck surgery emergencies and can result in significant morbidity with potential mortality. Traditionally, surgical incision and drainage (I&D) with antibiotics has been the mainstay of treatment. Some reports have suggested that ultrasound-guided drainage (USD) is a less invasive and effective alternative in select cases. OBJECTIVES: To compare I&D vs USD of well-defined DNAs, using a randomized controlled clinical trial design. The primary outcome measure was effectiveness (length of hospital stay (LOHS) and safety), and the secondary outcome measure was overall cost to the healthcare system. METHODS: Patients presenting to the University of Alberta Emergency Department with a well-defined deep neck space abscess were recruited in the study. Patients were randomized to surgical or US-guided drainage, placed on intravenous antibiotics and admitted with airway precautions. Following drainage with either intervention, abscess collections were cultured and drains were left in place until discharge. RESULTS: Seventeen patients were recruited in the study. We found a significant difference in mean LOHS between patients who underwent USD (3.1 days) vs I&D (5.2 days). We identified significant cost savings associated with USD with a 41% cost reduction in comparison to I&D. CONCLUSIONS: USD drainage of deep neck space abscesses in a certain patient population is effective, safe, and results in a significant cost savings to the healthcare system.

Teaching cricothyrotomy: a multisensory surgical education approach for final-year medical students.

OBJECTIVE: This study sought to evaluate the efficacy of a multisensory teaching approach in imparting the necessary knowledge, technical skills, and confidence to perform a cricothyrotomy to a cohort of fourth-year medical students. METHODS: One hundred twenty students were recruited into the study. Subjects commenced by viewing an upper airway obstruction vodcast. Students subsequently observed an expert demonstration of cricothyrotomy on human cadavers. Following this, students were able to practice on cadaveric simulators guided by experts. The students' confidence was assessed with pre- and post-session confidence-level questionnaires. Thirty randomly selected students were then assessed with a post-session objective skill assessment test. Finally, a multiple choice examination was administered to test knowledge. RESULTS: Ninety-five percent of student subjects achieved a score of at least 80% on the knowledge examination. All sampled students were considered competent to perform cricothyrotomy as judged by 2independent expert observers using the objective skill assessment test instrument. There was a statistically significant improvement between the pre- and post-CLQ scores (p<0.001). In keeping with current education theories on multisensory learning, qualitative feedback suggested a student preference for this teaching approach. CONCLUSION: This study provides further evidence that a multisensory teaching intervention effectively improves the knowledge, skill, and confidence of fourth-year medical students in performing cricothyrotomy.

Can a multisensory teaching approach impart the necessary knowledge, skills, and confidence in final year medical students to manage epistaxis?

OBJECTIVE: The purpose of this study is to evaluate the efficacy of a multisensory teaching approach in imparting the knowledge, skills, and confidence to manage epistaxis in a cohort of fourth year medical students. METHODS: One hundred and thirty four fourth year medical students were recruited into the study from Aug 2011 to February 2012 in four groups. Students listened to an audio presentation (PODcast) about epistaxis and viewed a video presentation on the technical skills (VODcast). Following this, students completed a 5-minute Individual Readiness Assessment Test (IRAT) to test knowledge accrued from the PODcast and VODcast. Next, students observed a 10-minute expert demonstration of the technical skills on a human cadaver and spent half an hour practicing these techniques on cadaver simulators with expert guidance. The students' confidence was assessed with Confidence Level Questionnaires (CLQs) before and after their laboratory session. The skill level of a subset of students was also assessed with a pre- and post-laboratory Objective Structured Assessment of Technical Skills (OSATS). RESULTS: Eighty two percent of the participants achieved a score of at least 80% on the IRAT. The CLQ instrument was validated in the study. There was a statistically significant improvement between the pre- and post-laboratory CLQ scores (p<0.01) and also between pre- and post-laboratory OSATS scores (p<0.01). Qualitative feedback suggested a student preference for this teaching approach. CONCLUSIONS: This study provides further evidence that a multisensory teaching intervention effectively imparts the necessary knowledge, skill and confidence in fourth year medical students to manage epistaxis.

Cost-effectiveness of positron emission tomography/computed tomography in the management of advanced head and neck cancer.

BACKGROUND: Positron emission tomography/computed tomography (PET/CT) is a newer imaging modality that combines whole-body PET using [(18)F]fluorodeoxyglucose (FDG) and contrasted high-resolution CT. This has the advantage of combining the functional imaging of FDG-PET with the anatomic detail afforded by CT. OBJECTIVE: To assess the cost-benefit of whole-body PET/CT as a diagnostic tool in head and neck cancer. METHODS: A retrospective cohort (American Joint Committee on Cancer III-IVB squamous cell carcinoma in 2003) was reviewed for costs of diagnostic tests, distant metastases, and treatment type. This was compared to a hypothetical cohort of patients using PET/CT as a sole diagnostic tool using the current literature on test characteristics in the detection of distant metastases. The main outcome measure was the cost of the diagnostic workup, and the secondary outcome measure was the cost of the treatment. RESULTS: The cost of the traditional workup was $450 per patient, whereas the cost of PET/CT workup was $722 per patient. The sensitivity of the traditional workup for lung metastases at 12 months was 14.3%. The average cost of curative surgery was $81,290, radiotherapy was $8,224, and chemotherapy was $1,158. In the cohort of 76 patients reviewed, improved PET/CT sensitivity would theoretically detect three more cases of metastatic disease and reduce the total cohort cost of treatment by $198,526 by relegating these patients to palliation. CONCLUSIONS: PET/CT is a more expensive test when used alone in the diagnostic workup of head and neck cancer but results in an overall cost savings by reducing the number of futile radical treatments. There is a cost benefit to the use of PET/CT as the diagnostic and staging test for head and neck cancer patients.

Intrahepatic collateral recanalization in symptomatic Budd-Chiari syndrome: a single-center experience.

The authors present a single-institutional experience with intrahepatic collateral vessel recanalization as a treatment option in symptomatic Budd-Chiari syndrome (BCS). Over a period of 26 months, this procedure was performed in four symptomatic patients in whom standard hepatic vein recanalization was not feasible or had failed, with a follow-up duration ranging from 7 to 44 months. Based on these cases, intrahepatic collateral vessel recanalization is a promising treatment option in suitable patients with symptomatic BCS and is deserving of further study.

Transjugular liver biopsy: a retrospective analysis of 601 cases.

PURPOSE: To perform a retrospective analysis of all transjugular liver biopsies (TJLBs) performed during a 77-month period. The authors discuss the technical modifications adopted to achieve better procedural success and histopathologic yield apart from the safety profile of this procedure during the study period. MATERIALS AND METHODS: Six hundred one consecutive patients underwent TJLB at the authors' institution during the study period. TJLB was performed when percutaneous biopsy was precluded, being judged unsafe. The left internal jugular vein (IJV) was accessed only when it was not possible to cannulate the right IJV, which was the routine access for this procedure. Biopsy samples were obtained from the right lobe after right hepatic vein cannulation. Left lobe biopsy was done only in select cases. In patients with shrunken liver and unfavorable hepatic veins for cannulation and in those with hepatic veno-occlusive disease, biopsy was performed with a transcaval approach under ultrasonographic (US) guidance, improving our technical success for this procedure over the years. RESULTS: The overall technical success rate for the procedure was 98.8 % (594/601), the histopathologic positivity was 97% (576/594), and the overall complication rate was 2.5% (15/601). CONCLUSIONS: With technical modifications such as transcaval liver biopsy and with access to US in the angiography suite, interventionalist can achieve higher technical success rates for this procedure. The authors' institutional experience with this procedure reiterates its high histopathologic positivity and safety profile both in adult and pediatric patients.

Nodular fasciitis.

A 24-year-old female presented with a firm, hyperpigmented, and gradually enlarging, tender, solitary dermal nodule of non-traumatic origin over the right suprascapular region. The lesion was extending into the subcutaneous tissue. She was otherwise normal. There was no calcification on X-ray. Biopsy revealed numerous large pleomorphic fibroblasts in a mucoid ground substance diagnostic of nodular fasciitis. No recurrence was noticed after surgical excision. This case is reported because of its rarity in the Indian medical literature.