Susceptibility-Weighted MRI as an Imaging Marker for Reperfusion Injury in Acute Ischemic Stroke Following Mechanical Thrombectomy.

Background/Purpose: Following endovascular intervention for stroke, hyperattenuated areas are common in brain parenchyma and it is difficult to differentiate on non-contrast CT whether it is contrast staining or reperfusion hemorrhage. Differentiation between contrast staining from reperfusion hemorrhage is of paramount importance for early initiation of antiplatelets and/or anticoagulants to prevent reocclusion of vessel. This study demonstrates signal characteristics of contrast-staining and reperfusion hemorrhage on susceptibility weighted MRI and its role to differentiate between two. Materials/Methods: Between July 2017 to March 2019, 36 patients who presented with acute ischemic stroke due to large vessel occlusion underwent mechanical thrombectomy. Low-osmolar non-ionic (Iopromide 300 mg/L) iodinated contrast was used in all patients who underwent endovascular intervention. All patients underwent noncontrast CT brain and SWI on 3T MRI within 30 minutes of endovascular intervention. MRI was evaluated by two neuroradiologists. Reperfusion hemorrhage was defined as ECASS criteria II. Symptomatic ICH was defined as hemorrhagic transformation temporally related to a negative shift in NIHSS score >/=4. Results: Out of 36 patients, 15 had hyperattenuated areas in brain on NCCT. Out of 15, 13 patients had blooming on SWI, suggestive of bleed. Two patients had no blooming on SWI, suggestive of contrast staining. Two patients didnot show any hyperdensity on NCCT but blooming on SWI, suggestive of bleed. Conclusion: All patients with hyperdensity on NCCT secondary to bleed showed blooming on SWI whereas those with contrast staining didnot show any signal changes on SWI. Thus, it is possible to differentiate reperfusion hemorrhage from contrast staining using SWI MRI. The significance of SWI in normal CT may be low where a small bleed maynot have any clinical significance.

Unusual manifestations of extra-pulmonary tuberculosis: a pictorial essay.

Purpose: Tuberculosis is quite common in India. About 40% of all Indians are infected with mycobacterium tuberculosis, with 2.5 million active tuberculosis cases. Tuberculosis primarily affects the lungs, but it can affect any organ. Extra-pulmonary involvement occurs 15-20% of cases in immune-competent patients and in more than 50% in HIV patients. The most common extra-pulmonary sites are lymph nodes, pleura, abdomen, genitourinary tract, skin, joints and bones, or meninges. Case reports: In this pictorial review article we present 8 atypical cases of tuberculosis and describe their imaging features and histopathology. Conclusions: Extra-pulmonary tuberculosis can affect virtually any organ and can mimic various inflammatory and neoplastic disorders apart from other infective conditions. A strong index of suspicion is required particularly in those countries endemic to tuberculosis.

Catastrophic Coronavirus Disease COVID Infection Leading to Gangrene of Foot in Peripartum Women.

Introduction: Pregnancy is a physiologically hypercoagulable state and a coronavirus disease 2019 (COVID-19) infection adds to this burden by accentuating the coagulopathy. We report two cases of severe peri-partum COVID infection leading to extremity gangrene secondary to a pro-thrombotic coagulopathy. Case One: A 37-year-old lady, day-2 postpartum, was brought with severe COVID infection & and respiratory failure. She developed progressive gangrene of the foot. A computed tomography (CT) angiogram confirmed the presence of thrombosis of the left external iliac & and common femoral artery. She was managed with catheter- directed thrombolysis and fasciotomy. The dry gangrene of the foot was managed with a Boyd's amputation. At 1-year follow-up, she is ambulant with a healthy stump. Case Two: A 34-year-old lady, 36 weeks of gestation, presented with fulminant COVID infection with respiratory failure and pulmonary embolus. The lady developed gangrene of the B/L toes. A CT angiogram revealed thrombosis below the popliteal trifurcation in both limbs along with segmental pulmonary thrombo-embolism involving the right lung and multiple splenic infarcts. She succumbed to the overwhelming infection and sepsis. Discussion: The pathogenesis of coagulopathy in pregnant COVID patients is attributed to the hypercoagulable effect, which leads to thrombo-embolisms and limb ischemia following a cytokine storm syndrome in severe infections. To date, this is the first experience detailing distal limb gangrene in fulminant COVID infection in peri-partum women. Although, cases have been reported on distal limb gangrene in severe COVID infection among non-pregnant individuals. Conclusion: A multidisciplinary team must manage COVID infections in the third trimester. A prompt recognition of any forms of lethal coagulopathy and vigilant treatment will prevent loss of life.

Ultrasound imaging for the differential diagnosis of periapical lesions of endodontic origin in comparison with histopathology - a systematic review and meta-analysis.

BACKGROUND: Differentiating periapical lesions is important for treatment planning and subsequent treatment outcome. OBJECTIVE: To assess the diagnostic accuracy of ultrasound imaging for the differentiation of periapical lesions in comparison with histopathology. METHODS: PubMed, Scopus, Embase, Web of Science and ProQuest databases were searched for clinical studies published until June 2020 that evaluated the use of ultrasound (US) imaging for differential diagnosis of periapical lesions and used histopathology as the reference standard. Animal studies, laboratory-based studies, reviews and clinical studies not using a reference standard were excluded. Risk of bias (RoB) assessment was performed using a modified Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. The random effects model was used for quantitative analysis of the data, and the Deeks test was used for calculating publication bias. Quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS: Twelve articles were included in the systematic review, out of which ten articles were quantitatively assessed. All the articles had a high RoB and concerns regarding applicability in the patient selection domain. For the index test domain, seven articles had low and the remaining five had unclear RoB and concerns regarding applicability. In the reference standard domain, low RoB and concerns regarding applicability were observed for all the articles. The RoB was low in flow and timing domains in all the articles except for one, where it was high. Summary estimates of sensitivity and specificity of US to diagnose periapical granulomas were 0.94 and 0.98, whereas for periapical cysts it was 0.98 and 0.99, respectively. Area under the curve for diagnosis of both periapical granulomas and periapical cysts was 0.99. All the included articles had inherent publication bias. Quality of evidence using GRADE, for sensitivity, was moderate for periapical granulomas and high for periapical cysts, whereas for specificity, it was high for periapical granulomas and low for periapical cysts. DISCUSSION: The available evidence is considered to be of low quality due to the observational nature of the studies and inherent publication bias. CONCLUSION: Although the sensitivity and specificity for differentiating periapical cysts and periapical granulomas using US were high, taking the quality of evidence into consideration, it can serve as an additional tool in differential diagnosis of periapical lesions.

Two Cases of Lingual Arteriovenous Malformations with Comorbidities Treated by Glue Embolization: A Report with Review of Literature.

Arteriovenous malformations (AVMs) involving the tongue are uncommon lesions in the head and neck region. They present with bleeding that can be massive and life-threatening apart from debilitating symptoms of pain, ulcers, difficulty in phonation or swallowing. Various therapeutic approaches have been used in their management-surgery, endovascular embolization, radiation and ablation procedures like laser ablation. We report two patients-a 34 year-old man and 56 year-old female who presented with massive bleeding due to lingual AVM and had comorbidities as liver cirrhosis and chronic medical renal disease respectively, and treated with glue embolization, with a review of the literature.

Recombinant Wolbachia surface protein (WSP)-induced T cell responses in Wuchereria bancrofti infections.

Human lymphatic filariasis is a debilitating parasitic disease characterized by downregulation of the host's immune response in asymptomatic carriers along with profound hyperreactivity in chronic patients apart from putatively immune endemic normals. The endosymbiont Wolbachia, a bacterium of filarial nematodes has received much attention as possible chemotherapeutic target and its involvement in disease pathogenesis. The role of recombinant Wolbachia surface protein (rWSP), one of the most abundantly expressed proteins of the endosymbiont, in modulating cell-mediated immune responses in patients harboring Wuchereria bancrofti infections was evaluated in the current study. rWSP-induced lymphoproliferation with peripheral blood mononuclear cells suggested an impaired proliferative response in asymptomatic microfilaremic (MF) and symptomatic chronic pathology (CP) patients compared to endemic normals (EN). This was further supported by a significantly diminished expression of CD69 along with elevated levels of CD127 and CD62L in filarial patients (MF and CP) compared to EN. Further, rWSP induced the expression of regulatory T cell markers CTLA-4 and CD25 along with suppressor cytokines IL-10 and TGF-ß in MF and CP patients compared to EN. However, the rWSP-stimulated expression of IFN-γ was diminished significantly in filarial patients compared to endemic normals. Thus, these findings suggest that WSP may also contribute to the suppression of immune responses seen in filarial patients.

Recombinant Wolbachia heat shock protein 60 (HSP60) mediated immune responses in patients with lymphatic filariasis.

Wolbachia, an endosymbiont present in filarial nematodes, have been implicated in a variety of roles, including the worm development and survival. Elucidation of the role of Wolbachia in filarial nematode biology and pathogenesis has become the focus of many studies and its contribution to parasite survival or immune response is still unclear. Recombinant Wolbachia HSP60 decreases T cell activation and lymphoproliferation in filarial infected people compared to endemic controls as observed by the assessment of T cell activation markers and cytokine responses in the peripheral blood mononuclear cells. Reduced T cell activation may be linked to T regulatory cell activity since it is associated with increased expression of CTLA4 and CD25 on CD4(+) T cells in filarial infected group upon stimulation with recombinant Wolbachia HSP60. In addition, elevated interleukin-10 and TGF-ß cytokines corroborate the reduced CD4(+) T cell activation and interferon-γ observed upon recombinant Wolbachia HSP60 stimulation in filarial patients. Hence, these findings indicate that Wolbachia HSP60 may also contribute to the immune modulation seen in filarial patients.

Immune responses to recombinant Brugia malayi pepsin inhibitor homolog (Bm-33) in patients with human lymphatic filariaisis.

Immune responses to recombinant Brugia malayi pepsin inhibitor homolog (rBm-33) were investigated in patients with human lymphatic filariasis (microfilaremics (MF) and chronic pathology (CP)) along with endemic normals (EN). Flow cytometric analysis (24 h) revealed CD4(+) T cell activation in patients (MF and CP) compared to normals (EN), with increased expression of CD69 and diminished levels of CD62L and CD127. This was associated with an elevated expression of CD154 but not CD28 and CTLA4 in CP patients. However, Bm-33-induced cytokine expression profile (IL-1ß, IL-12, IL-8, IFN-γ, IL-10 and TGF-ß) did not exhibit any significant difference between normals and patients at the same time point. Although CD4(+) T cell activation was observed initially in filarial patients (24 h), lymphoproliferation studies (96 h) suggested diminished proliferation compared to normals, indicating functional inactivation in the former upon prolonged antigen exposure. This indicates that rBm-33 induces an early T cell activation in MF and CP patients followed by a decreased lymphoproliferation that might contribute to immune suppression in these individuals.

Wuchereria bancrofti: diminished platelet activation in filarial patients.

Blood platelets are the innate immune elements that have not been investigated in human filarial infections. Platelet activation status in the endemic normals (EN), microfilaria positive individuals (MF) and patients with chronic pathology (CP) was evaluated in whole blood, under unstimulated as well as antigen exposed (BmA, E. coli) conditions for PAC-1 expression by Flow cytometry. A diminished PAC-1 expression was observed in MF compared to CP and EN spontaneously as well as upon antigen exposure. Besides this, PAC-1 expression within the groups did not exhibit any significant difference under all the experimental conditions. However in CP patients, E. coli antigen exposure resulted in a significantly reduced PAC-1 expression compared to the spontaneous expression levels. NO release in platelet culture supernatants from EN was inversely proportional to platelet aggregation. Collagen stimulated platelets from EN, exposed to sera and immune complexes from CP and MF patients resulted in elevated Nitric Oxide (NO) release, compared to those exposed to autologous sera and fetal calf serum. In addition, under similar conditions, collagen stimulated platelets from EN, exposed to filarial antigen (BmA) exhibited increased NO compared to the E. coli antigen exposed ones and light microscopic observations of cultured platelets supported the above findings. Thus it appears from the results of the present study that filarial antigen may play a role in the loss of platelet aggregation, leading to platelet inactivation.

A study on the resting preference of mosquito species in wells in Vellore in Tamilnadu, South India.

The resting preferences of mosquito species was investigated in domestic wells. In addition to the routine adult surveys in human dwellings, adult collections were also made in domestic wells using an innovated equipment operating on the principles of spray sheet collections. Above the water surface, wells provide humid and dark microclimate along the inner walls. It has been observed that this microclimate provides very congenial resting place for few mosquito species; specially for the males and for the females between their gonotropic cycles. Larval collections in the wells did not reveal breeding of majority of the mosquito species collected by this technique. Investigations were conducted in 87 wells in 11 localities during 2005. A total of 4969 mosquitos were collected of which 69.1% (3441) were males and 30.9% (1528) were females. From among the mosquitos collected 96.5% were Cu. quinquifasciatus, 0.26% All stephensi, 3.0% Aedes agypti and 0.24% Armegeres sp. The results of the analysis of the physical and chemical parameter of water samples of the study wells before and after the surveys endorsed the utility of this technique for entomological investigations in outbreak situations, for monitoring the liquidation of outbreak foci and for other research purposes.

Portfolio as a learning tool: students' perspective.

Portfolio writing is a method of encouraging reflective learning among professionals. Although portfolio-based learning is popular among educators, not many studies have been done to determine students' perceptions of portfolio as a learning tool. A questionnaire survey was conducted among 143 medical students to find out their perceptions of the portfolio as a learning tool. A majority of the students felt that the portfolio is a good learning tool. However, they also perceived that it is stressful and time-consuming to develop a proper portfolio. The study indicates that students need appropriate guidance from the academic staff for the system to succeed.

Hearing impairment in the elderly.

Hearing impairment is one of the most important health problems of the elderly above 60. Very often it leads to verbal communication difficulty and without treatment it can cause serious psychological and social complications such as depression and social isolation. Prebyscusis remains a leading cause of sensorineural deafness in the elderly. Elderly patient must be encouraged to seek proper hearing assessment if they face hearing difficulty. Active screening by health care workers and patient self-evaluation by answering a simple list of screening questions are possible for early detection and treatment of hearing loss in the elderly. Although hearing loss in the elderly may not have a cure, early rehabilitation helps to restore better quality of life if the problem is detected early.

Recent trends in the diagnosis and management of allergic rhinitis.

Allergic rhinitis is a global health issue and its prevalence is increasing. Allergic rhinitis and asthma coexist in many patients. Allergic rhinitis is an Ig E mediated reaction. Prostaglandins and Leukotriens do not play a significant role in the pathogenesis of allergic rhinitis. Skin prick test and Enzyme linked immunosorbent assays (ELISA) are useful as diagnostic tests. The three major modalities of treatment for allergic rhinitis are allergen avoidance, pharmacotherapy and immunotherapy.

Medical negligence suits: risk management.

Medical negligence suits have become an issue of concern for doctors as well as for the health service departments. The main objectives of medical malpractice law are to compensate patients who are injured by negligence and to improve the quality of medical care. The amount of money and time spent on these cases may not be an effective allocation of social resources to minimize patient safety. Though physicians generally win more malpractice suits, much time and money are spent and results in much stress to those concerned. There are certain controllable events in practice that render a physician more or less vulnerable to malpractice claims. Attempts by physicians to understand and prevent unwanted situations that can lead to litigation is important. The risk factors for medical negligence suits are discussed. The practice of good medicine will be the best form of risk management.

Impact of integration of NLEP into PHC system in Madurai district, Tamil Nadu, and status of integration of leprosy patients into the community.

Based on the encouraging results of the integration in Tamil Nadu, the Government of India introduced integration in the entire country. In this study on integration, Madurai district was taken as the study area. The impact of integration on essential indicators of leprosy elimination was analyzed and the results are discussed so that they will be useful to other states that are still considering integration.

Reevaluating the use of antibiotics in acute otitis media in children.

Increasing concern about the antibiotic resistance in acute otitis media (AOM) has led to debate over use of antibiotic in AOM and duration of therapy. Many studies have proved that watchful waiting should be used more often for acute otitis media. In children over two years, the most appropriate treatment was found to be initial observation followed by 5 days of an antibiotic if the child failed to improve spontaneously. In children less than 2 years or one with severe symptoms antibiotic can be started after 24 hours if there is no improvement with symptomatic treatment. Physician should be more selective in the prescription of antibiotics early in AOM.

Oesophageal perforation presenting as oesophageal atresia in a premature neonate following difficult intubation.

Iatrogenic oesophageal perforation in neonates is well recognized in the medical and surgical literature with intubation injury listed as a possible contributing mechanism besides nasogastric tube placement and suctioning. Diagnosis can be difficult and sometimes confused with other entities. With early diagnosis, nonsurgical management often leads to complete resolution in neonates. We report the case of a 1-day-old premature neonate who was brought to the operating room with the preliminary diagnosis of proximal oesophageal atresia with stump perforation and distal tracheo-esophageal fistula. His intubation for respiratory distress at birth had been difficult due to Pierre-Robin sequence with micrognathia. Oesophagoscopy in the operating room revealed a patent oesophagus but perforations in the pharynx and in the proximal oesophagus with the nasogastric tube entering the pharyngeal perforation. Oesophageal perforation and the limitations of the difficult airway algorithm in small neonates are discussed.

A study of health and health related social problems in the geriatric population in a rural area of Tamil Nadu.

About 200 individuals aged 60 years and above, out of 317 total geriatric population of a small village in Tamil Nadu were subjected for complete clinical examinations with the objective of finding major health problems and associated social problems prevalent among these study population. Main causes of illness were found to be arthritis, cataract, bronchitis, skin diseases and malnutrition.