Diagnostic Utility of Direct Immunofluorescence on Paraffin-Embedded Skin Biopsy Samples for the Diagnosis of Autoimmune Vesiculobullous Lesions.

Background Autoimmune vesiculobullous diseases (AIBDs) are a group of diseases characterized by blisters of the skin/mucosa due to the presence of circulating autoantibodies against antigens in the epidermis or the dermo-epidermal junction. Direct immunofluorescence (DIF) for immunoglobulin (Ig)G, IgC3, and IgA on fresh-frozen tissue is the gold standard diagnostic test for AIBDs. However, DIF in the absence of frozen tissue is challenging for the diagnosis of AIBDs. This study aimed to analyze the practical utility of DIF using paraffin-embedded skin biopsy rather than fresh frozen tissue for the diagnosis of AIBDs. Methodology This cross-sectional comparative study included 30 cases of AIBDs. DIF for IgG and IgA was performed on paraffin-embedded tissue (PE-DIF) after proteinase digestion on histopathologically confirmed 15 pemphigus vulgaris (PV), three pemphigus foliaceous (PF), four bullous pemphigoid (BP), three dermatitis herpetiformis (DH), three subcorneal pustular dermatosis (SCPD), and one case each of linear IgA disease and pemphigoid gestationis (PG). PE-DIF staining pattern was compared with the DIF on fresh frozen tissue (FF-DIF). Results All cases of PV and PF showed an intercellular IgG chicken wire staining pattern similar to FF-DIF. However, background staining was more intense in PV cases while less intense in PF cases. Three BP cases showed linear IgG staining in PE-DIF. DH, SCPD, linear IgA disease, and PG cases did not show IgG positivity. Out of three DH cases, two cases showed granular IgA positivity while linear IgA positivity along the basement membrane was seen in a single case of linear IgA disease. Negative IgG staining was observed in SCPD. Immunofluorescence in PE-DIF was rapidly deteriorating than in FF-DIF. Conclusions DIF done on paraffin-embedded tissue can be used as a supplement and salvage technique with histopathology for the diagnosis of AIBDs, particularly when a cryostat facility for frozen tissue is not available and the patient is unable to undergo a second biopsy procedure.

Neurovascular Structures at Risk During Surgical Access to Trigeminal Ganglion and Meckel's Cave - An Anatomical Study.

Background: It is difficult to approach the Trigeminal Ganglion (TG) and Meckel's cave (MC) during surgeries. Therefore, the exact knowledge of the relationship of surgical landmarks to related anatomical structures is vital to reduce the associated postoperative morbidity. The aim of the present study was to enhance the knowledge of the surgical anatomy of structures that are present in the conduit of all surgical approaches to TG and MC, their distances from surrounding neurovascular structures, and their variations. Material and Methods: The study was carried out on 40 embalmed cadavers (Eight Female) of the anatomy department of a teaching hospital in Central India. Meticulous dissection of cranial fossae was done to locate TG, MC, and related anatomical structures. All distances from TG and MC were measured using an electronic digital calliper. Results: Length, width, and thickness of TG were 15.39 mm, 4.39 mm, and 2.54 mm, respectively. The distance from zygomatic arch, the lateral end of the petrous ridge, arcuate eminence, foramen ovale, and foramen spinosum to MC was 26.10 mm and 37.94 mm, 16.46 mm, 4.54 mm, and 11.23 mm, respectively. The sixth, fourth, and third cranial nerves were 6.26 mm, 4.94 mm, and 2.53 mm from MC, respectively. The MC was 42.72 mm and 33.87 mm anteromedial from posterior and anterior limits of the sigmoid sinus. Conclusion: Findings of the present study will aid surgical planning and decide the approach to TG and MC and avoid surgical complications.

Case-based learning: A 'Case' for restructuring anatomy education in Indian nursing curriculum.

BACKGROUND: Teaching anatomy in a clinical context can aid students in appreciating how the subject will apply to their future career as nurses as well as in other administrative roles. Anatomy is voluminous, making it difficult to retain the factual information in the long run; therefore, this study primarily focuses on whether case-based learning (CBL) with integrated anatomy learning can help in retention of the information over short as well as long spans of time. It also focuses on how profitable would the students be with this different style of learning, and whether it can facilitate in better understanding of the basic and clinical concepts. MATERIALS AND METHODS: The current study was conducted in the Nursing College of All India Institute of Medical Sciences, Bhopal, India to integrate CBL and evaluate its effect compared to the highly compartmentalized, didactic lectures among the nursing students. The extent of knowledge retention was analyzed by conducting a series of tests before as well as after CBL intervention. Feedback and suggestions were obtained from the students by using the 5-point Likert scale method. RESULTS: The post-test scores of the students improved by 21% after the CBL. More than 85% of the students opined that CBL improves critical thinking, team work, self-directed learning, and communication skills. CONCLUSION: CBL promotes effective short-term retention and facilitates comprehension of key concepts. CBL also plays an important role in improving the professional skills of the students, which otherwise is not taught, and equips them for their future careers.

Mutations of PHOX2B Gene in Patients of Obesity Hypoventilation Syndrome in Central India.

Background Paired-like homeobox 2B (PHOX2B) gene on chromosome 4p12 codes for a transcription factor having a role in the formation of noradrenergic neuronal circuits. Its mutations have been linked to congenital central hypoventilation syndrome (CCHS). The clinical presentation of both, obesity hypoventilation syndrome (OHS) and CCHS in adults (named late-onset central hypoventilation syndrome), is quite similar. Because of this symptomatic similarity, multifactorial causation of OHS, the mutation of PHOX2B gene was studied in patients with OHS in this study. Methods A hospital-based cross-sectional study was performed on patients diagnosed with OHS. The deoxyribonucleic acid was extracted from 2 mL of venous blood and was further amplified, specific to exon 3. The amplified products were cast and run in 2% agarose gel and then subjected to Sanger sequencing. Results Thirty patients of OHS (21 male; 9 female) were enrolled in the present study, average age being 51.7 years. The Sanger sequencing of the samples revealed no apparent areas of deletions and no apparent mutations. Conclusion Primers for exon 3 were used for amplification in thermocycler, as exon 3 is the most frequently mutated exon for PHOX2B gene, as per existing literature. The entire gene needs to be studied for mutations and the sample size needs to be increased.

Comparison of the effect of in vitro and in vivo exposure on cadaveric anxiety among first year medical and nursing students.

BACKGROUND: Human anatomy instruction is mostly focused on cadaver dissection and prosected specimen examination. Exposure to cadaver dissection can be a stressful experience that may cause a wide variety of symptoms among students of health sciences. To compare and evaluate the effect of in-vitro and in-vivo exposure on cadaveric anxiety, disgust propensity and sensitivity, and attitude toward death and dying among 1st-year medical and nursing students. MATERIALS AND METHODS: An open-label randomized trial (matched-control experimental design) was conducted among 127 1st-year Medical and Nursing students from a selected Institute of National Importance, Bhopal, India during 2015. The participants were divided into an experimental and control group based on matched trait anxiety scores using the Trait Anxiety Inventory. Followed by preassessment, video demonstration with cadaver dissection (in vitro exposure) was then administered to the experimental group, while the control group had direct exposure to cadaver dissection (in vivo exposure). RESULTS: The study showed that there was a statistically significant difference in state anxiety related to cadaver dissection in the experimental group (P = 0.01). However, video-demonstration of cadaver dissection did not have any effect on disgust propensity and sensitivity and attitude toward death and dying. CONCLUSION: The findings provided evidence that video-demonstration of cadaver dissection reduced anxiety, although it did not have any effect on disgust and attitudes of death. The dissection hall experience may evoke feelings of anxiety and disgust that need to be addressed through advanced preparedness and coping strategies, especially among medical and nursing students.

Assessment of the Effect of Smartphone Usage on the Range of Motion and Fatigability of the Joints and Muscles of the Thumb Among Users: A Cross-Sectional Study in Central India.

Introduction The ability of adaptation is unique to humankind. Technology advances have introduced many appliances that increasingly are smaller in size and handheld. These devices on prolonged usage affect the thumb joint complex, and this study was therefore designed to assess any changes in the movement of the thumb joint complex and fatigability secondary to the increasing usage of smartphones in different orientations in the Central Indian population. Materials and methods An analytical cross-sectional study was performed to assess changes in the ranges of motion (ROM) of the thumb joint complex with a sample size of 137 selected nonrandomly and categorized on the basis of the orientation of smartphone usage by physical goniometer and a standardized questionnaire to assess fatigability. Results Most movements of the thumb joint complex corresponded to the existing standard values. The study found significant changes in the movement of passive flexion of the left metacarpophalangeal (MCP) joint and borderline significant modifications in the active extension of the left interphalangeal (IP) joint, passive extension of the left interphalangeal joint, and passive flexion of the left carpometacarpal (CMC) joint among the groups of participants. The Borg CR10 value of fatigue was "one," indicative of no excessive fatigue after smartphone usage. Conclusion There are no significant changes in the ranges of motion of the joint complex of the thumb in mobile phone users over a period of time. The orientations and the increased duration of usage also did not cause any fatigue in the muscles of the thumb.

Morphologic Features of the Distal Femur and Proximal Tibia: A Cross-Sectional Study.

Background The asymmetric medial and lateral condyles of the distal femur and proximal tibia have a direct influence on the biomechanics of knee joint and prostheses design. This study aimed to determine the morphologic data, that is., anteroposterior (AP) and mediolateral (ML) widths, and the radius of curvature (ROC) of the geometric arcs of the distal femur and proximal tibia. Methods One hundred and seventeen adult dry bones (57 femurs and 60 tibias) were studied. Aspect ratios (AP/ML) were calculated. The AP and ML widths were measured using digital Vernier Caliper with a measuring range of 0-150 mm, resolution of 0.01 mm, and accuracy ± 0.02 mm. The geometric arcs of femoral and tibial condyles were divided into three parts namely anterior 1/3rd, distal (femur) or middle (tibia) 1/3rd and posterior 1/3rd and were estimated in the sagittal plane for the femur and transverse plane for tibia using the ROC gauges. Results For the femur, the mean AP length for medial and lateral condyles was 55.62 mm and 57.93 mm, respectively, while the mean ML width was 73.45 mm. For the tibia, the mean AP length for medial condyle (MC) and lateral condyle (LC) was 47.74 mm and 43.46 mm, respectively. The mean aspect ratios for the distal femur and proximal tibia were 1.26 and 1.45, respectively. The mean aspect ratios for MC and LC of the femur were 0.50 and 0.52, respectively, whereas, for tibia, they were 0.61 and 0.71, respectively. The mean ROC for femoral MC - 20.77 mm, 31.42 mm, and 19.68 mm and for LC - 21.48 mm, 64.40 mm and 19.06 mm for the anterior, distal and posterior arcs, respectively. The mean ROC for tibial MC - 22.42 mm, 22.49 mm and 19.94 mm, and LC - 19.92 mm, 21.79 mm and 20.95 mm for the anterior, middle and posterior arcs, respectively. Conclusions The morphologic data accumulated in this study for both the distal femur as well as the proximal tibia would provide guidelines and help the manufacturers of joint prostheses to address the potential for compromised implant fit and re-design and make available 'anatomic' knee prostheses appropriate for the local population which would not only improve function but also prolong the longevity of the prostheses.

Correlation Between the Thickness of Anterolateral Ligament and Lateral Collateral Ligament of the Knee.

Background Persistent anterolateral rotatory instability (ALRI) following the anterior cruciate ligament (ACL) reconstruction has led to a renewed interest in defining the role of anterolateral complex (ALC) of the knee. Methods We explored the anterolateral corner of 34 cadaveric knees to define the anterolateral ligament (ALL) in all its dimensions and measured the thickness of lateral collateral ligament (LCL) at the lateral meniscus level (tLCL) in ALL-intact and ALL-deficient knees. Results ALL was present in 27/34 (79%) of the knees. We found complete ALL in 13 cadavers bilaterally. ALL was absent bilaterally in three cadavers; it was present on one side and absent contralaterally in one cadaver. In ALL-intact knees, the average tLCL was 2.05 mm, whereas, in ALL-deficient knees, it was 2.57 mm. This difference in tLCL was statistically significant. Conclusions Our study adds new data to the recent voluminous research on ALL. We have examined the correlation between the thickness of ALL and LCL and documented alterations in the thickness of LCL in ALL-intact knees. These findings would help in designing reconstructive procedures for the combined ACL injury with ALRI.

Surgical Implications of Innervation Pattern of the Triceps Muscle: A Cadaveric Study.

The innervation pattern of triceps is complex and not fully comprehended. Anomalous innervations of triceps have been described by various authors. We have attempted to delineate the nerve supply of the triceps and documented the anomalous innervations of its different heads. The brachial plexus and its major branches (in the region of the axilla and arm) and triceps were dissected in 36 embalmed cadaver upper limbs. Long head received one branch from radial nerve in 31 (86%) specimens. Four (11%) specimens received two branches including one that had dual innervation from the radial and axillary nerves, and one (3%) specimen had exclusive innervation from a branch of the axillary nerve. Medial head received two branches arising from the radial nerve in 34 (94%) specimens. One (3%) specimen received three branches from the radial nerve whereas one (3%) had dual supply from the radial and ulnar nerves. Lateral head received multiple branches exclusively from the radial nerve, ranging from 2 to 5, in all (100%) specimens. Knowledge of the variations in innervation of the triceps would not only help the surgeon to avoid inadvertent injury to any of the nerve branches but also offers new options for nerve and free functional muscle transfers.

Risk of nerve injury during arthroscopy portal placement in the elbow joint: A cadaveric study.

BACKGROUND: Elbow arthroscopy has become a routine procedure now. However, placing portals is fraught with dangers of injuring the neurovascular structures around elbow. There are not enough data documenting the same amongst the Indians. We aimed to determine the relative distances of nerves around the elbow to the arthroscopy portals and risk of injury in different positions of the elbow. MATERIALS AND METHODS: Six standard elbow arthroscopy portals were established in 12 cadaveric upper limbs after joint distension. Then using standard dissection techniques all the nerves around the elbow were exposed, and their distances from relevant portals were measured using digital vernier caliper in 90° elbow flexion and 0° extension. Descriptive statistical analysis was used for describing distance of the nerves from relevant portal. Wilcoxon-signed rank test and Friedman's test were used for comparison. RESULTS: There was no major nerve injury at all the portals studied in both positions of the elbow. The total incidence of cutaneous nerve injury was 8.3% (12/144); medial cutaneous nerve of forearm 10/48 and posterior cutaneous nerve of forearm 2/24. No significant changes were observed in the distance of a nerve to an individual portal at 90° flexion or 0° extension position of the elbow. CONCLUSION: This study demonstrates the risk of injury to different nerves at the standard portals of elbow arthroscopy. In practice, the actual incidence of nerve injury may still be lower. We conclude that elbow arthroscopy is a safe procedure when all precautions as described are duly followed.

An Anatomical Study to Demonstrate the Proximity of Kirschner Wires to Structures at Risk in Percutaneous Pinning of Distal Radius Fractures.

Distal radius fractures are often treated using percutaneous Kirschner wires (K-wires). The sensory nerves in this area, extensor tendons, radial artery and cephalic vein are at risk of injury in this procedure. We undertook a cadaveric investigation to identify probability of damage to these 'at risk' structures by measuring their distances in relation to standard K-wire sites. Nine upper limbs from six formalin-preserved cadavers were studied. Four K-wires were placed percutaneously simulating fixation of a distal radius fracture. Careful dissection was done preserving the original position of neurovascular and tendinous structures. Distances to relevant soft-tissue structures from each K-wire were measured using an electronic digital caliper. Distance of superficial nerves from radial styloid and Lister's tubercle was measured to determine their 'safe distance' from these fixed landmarks. None of the superficial nerves were injured by a K-wire. Cephalic vein had been pierced on 4 occasions (4/18) and extensor tendons on 3 occasions (3/18). Wilcoxon signed-rank test was used to compare distance of the superficial nerves from radial styloid and Lister tubercle, and the latter was found to be the safer option. This study highlights the inherent danger in percutaneous K-wire fixation of wrist fractures. Limited size of the area, where K-wires can be positioned, and anatomic variations of neurovascular structures pose obstacles in developing guidelines for reducing risk of injury. We advocate use of mini-open approach and guiding devices to avert complications of inadvertent impalement and damage to these structures.

Rare multiple variations in brachial plexus and related structures in the left upper limb of a Dravidian male cadaver.

Anatomical variations of the nerves, muscles, and vessels in the upper limb have been described in many anatomical studies; however, the occurrence of 6 variations in an ipsilateral limb is very rare. These variations occur in the following structures: the pectoralis minimus muscle, the communication between the external jugular vein and cephalic vein, axillary arch, the Struthers ligament, the medial, lateral, and posterior cords of the brachial plexus, and the common arterial trunk from the third part of the axillary artery. The relationship of these variations to each other and their probable clinical presentation is discussed.

Introduction of vertical integration and case-based learning in anatomy for undergraduate physical therapy and occupational therapy students.

The purpose of the present pilot study was to evaluate the benefits of innovative teaching methodologies introduced to final year occupational and physical therapy students in Christian Medical College in India. Students' satisfactions along the long-term retention of knowledge and clinical application of the respiratory anatomy have been assessed. The final year undergraduate physical therapy and occupational therapy students had respiratory anatomy teaching over two sessions. The teaching involved case-based learning and integrated anatomy lectures (vertical integration) with the Anatomy department. Pretest and immediate and follow-up post-tests were conducted to assess the effectiveness of the innovative methods. A feedback questionnaire was marked to grade case-based learning. The method of integrated and case-based teaching was appreciated and found to be useful in imparting knowledge to the students. Students retained the gained knowledge adequately and the same was inferred by statistically significant improvement in both post-test scores. Vertical integration of anatomy in the final year reinforces their existing knowledge of anatomy. Case-based learning may facilitate the development of effective and clinically sound therapists.