Genu valgum deformity - correction by a wedgeless implantless femoral "V" osteotomy.

Coronal malalignment of the knee joint is very common in developing countries especially because of nutritional rickets. Significant valgus deformity needs to be treated surgically to improve appearance, gait and function of the patient. The purpose of this prospective study was to evaluate the results of supracondylar "V" osteotomy as a surgical technique for correction of the valgus knee deformity. This study was conducted in a tertiary level teaching hospital and 30 cases were included in the study. For all the patients deformity was assessed using ana- tomical tibiofemoral angle, mechanical axis deviation and intermalleolar distance preoperatively and post- operatively. The average age of our patients was 13.7 years and the average follow up was3.29 years (1.39-14.22 yrs). Clinically the average value of intermalleolar distance preoperatively was 16cm and 3.2 cm postperatively. Average pre-operative tibiofemoral angle was 23° and the average postoperative angle was 6 0 which was found to be statistically significant using the Paired t test (p<0.005). The average value of preoperative mechanical axis deviation was 3.1 cm which decreased to an average value of 1.1 cm postoperatively. The results with this technique have been encouraging. The advantages of this technique are low morbidity, good stability allowing early ambulation, ability to adjust alignment postoperatively by casting and no need for internal fixation. Few studies have been conducted on osteotomies that do not require internal fixation and are inherently stable. This technique has the advantage of practically no occurrence of any infection or a second surgery to remove hardware in children and adolescents. Since no specialized instrumentation, image intensifier and implants are required, it is cost effective and can be used in any primary care or district level surgical setup in a developing country like ours.

Effect of Q-switched Nd-YAG laser on the clinical, pigmentary, and immunological markers in patients with lichen planus pigmentosus: A pilot study.

The persistent discoloration in lichen planus pigmentosus (LPP) is secondary to persistent melanophages in the superficial dermis in these patients. We evaluated the effect of Q-switched Nd-YAG laser on the clinical, pigmentary, and immunological markers in patients with LPP. Nine females with a clinical diagnosis of LPP were included in the study. After six sessions of laser with toning protocol, performed over a representative area of 5 × 5 cm2 at 2-weekly intervals, the mean clinical improvement as per the physician assessment was 25.7% (10-40%). There was no significant reduction in melanin and erythema index. On expression analysis using quantitative-polymerase chain reaction, the reduction in tyrosinase (p = 0.03) was statistically significant, though, the reduction in other pigment and immunological markers was not significant. The immunohistochemistry quantification data of corresponding proteins also did not show any significant difference. Post inflammatory hypopigmentation was noted in one patient. Q-switched Nd-YAG laser toning protocol resulted in modest clinical and histological improvement in patients of LPP.

A randomised controlled trial comparing the efficacy of micellised and fat-soluble vitamin D3 supplementation in healthy adults.

Nanoemulsion formulation of vitamin D3 have been shown to have better bioavailability than the coarse emulsion preparation in vitro and in vivo animal studies. In the absence of randomised trial in humans, comparing the efficacy of nanotechnology-based miscellised vitamin D3 over conventional vitamin D3, we undertook this study. A total of 180 healthy adults were randomised to receive either micellised (DePura, group A) or conventional vitamin D3 (Calcirol, group B) at a monthly dose of 60 000 IU (1500µg) for 6 months. The outcome parameters were serum 25-hydroxyvitamin D (25(OH)D), parathyroid hormone (PTH), Ca, phosphate, alkaline phosphatase and urinary Ca:creatinine ratio. A total of eighty-nine subjects in group A and seventy-seven in group B completed the trial. Subjects in both the groups had a significant increase in their serum 25(OH)D levels following supplementation (group A: 21·5 (sd 10·9) to 76·7 (sd 18·8) nmol/l (P<0·001); group B: 22·8 (sd 10·4) to 57·8 (sd 16·0) nmol/l (P<0·001)). Participants in micellised group had an additional increase of 20·2 (95 % CI 14·0, 26·4) nmol/l in serum 25(OH)D levels (P<0·001). The difference between the groups was 17·5 (95 % CI 11·8, 23·1) nmol/l, which remained statistically significant (P<0·001) even after adjustment for age and sex. Significant decline in mean serum PTH was observed in both the groups. No hypercalcaemia or hypercalciuria was noted. Although supplementation with both the preparations resulted in a significant rise in serum 25(OH)D levels, micellised vitamin D3 appeared to be more efficacious in achieving higher levels of serum 25(OH)D.

T helper type 1 polarizing γδ T cells and Scavenger receptors contribute to the pathogenesis of Pemphigus vulgaris.

γδ T cells and Scavenger receptors are key parts of the innate immune machinery, playing significant roles in regulating immune homeostasis at the epithelial surface. The roles of these immune components are not yet characterized for the autoimmune skin disorder Pemphigus vulgaris (PV). Phenotyping and frequency of γδ T cells estimated by flow cytometry have shown increased frequency of γδ T cells (6·7% versus 4·4%) producing interferon- γ (IFN-γ; 35·2% versus 26·68%) in the circulation of patients compared with controls. Dual cytokine-secreting (IFN-γ and interleukin-4) γδ T cells indicate the plasticity of these cells. The γδ T cells of patients with PV have shown higher cytotoxic potential and the higher frequency of γδ T cells producing IFN-γ shows T helper type 1 polarization. The increased expression of Scavenger receptors expression (CD36 and CD163) could be contributing to the elevated inflammatory environment and immune imbalance in this disease. Targeting the inflammatory γδ T cells and Scavenger receptors may pave the way for novel therapeutics.

Utility of Horizontal Sections of Scalp Biopsies in Differentiating between Androgenetic Alopecia and Alopecia Areata.

BACKGROUND: Androgenetic alopecia (AGA) and alopecia areata (AA) are common causes of alopecia which can sometimes be difficult to differentiate clinically. Horizontal sections of scalp biopsies are used to study non-cicatricial alopecias due to the ability to perform both quantitative and morphometric analysis of hair follicles on them. METHODS: It was a prospective, cross-sectional study conducted to assess the utility of horizontal sections to differentiate between the alopecias. Fifty-two cases were included: 20 cases of male AGA, 11 of female AGA and 21 cases of AA. After clinical examination and dermoscopy, a skin biopsy was taken and subjected to transverse sectioning. Histopathological assessment was done by two dermatopathologists blinded to clinical details. RESULTS: Among the quantitative parameters, terminal:vellus hair ratio (3.08 in AGA and 1.83 in AA, p = 0.0091) and anagen:non-anagen hair ratio (9.25 in AGA and 3.56 in AA, p = 0.0021) were significantly lower in AA. In qualitative parameters, peribulbar inflammation was seen in 63% of AA cases (p = 0.0001). Pigment casts were seen in twice the number of AA (57%) than AGA (26%) cases. Broad avascular stelae and focal trichomalacia were seen in 9.5% of AA cases. CONCLUSION: Besides peribulbar inflammation, we found a lower anagen:non-anagen hair ratio and presence of pigment casts in transverse sections of scalp biopsies favouring AA over AGA.

Genotype-Phenotype Correlations of Dystrophic Epidermolysis Bullosa in India: Experience from a Tertiary Care Centre.

Recent advances in the field of genomics have seen the successful implementation of whole exome sequencing as a rapid and efficient diagnostic strategy in several genodermatoses. The aim of this study was to explore the potential of molecular studies in dystrophic epidermolysis bullosa (DEB) in India. Whole exome sequencing was performed using genomic DNA from each case of epidermolysis bullosa, followed by massively parallel sequencing. Resulting reads were mapped to the human reference genome hg19. Sanger sequencing subsequently confirmed the potentially pathogenic mutations. Whole exome sequencing of 18 patients with DEB from 17 unrelated Indian families revealed 20 distinct sequence variants in the COL7A1 gene including 2 widely prevalent mutations. Dominant inheritance was seen in 7 patients, while 11 patients showed a highly variable recessive DEB. This preliminary study using exome sequencing is clearly encouraging and will serve as the basis for future large-scale molecular studies to actively identify and understand DEB in the Indian population.

Differentiating the Effects of Familial Risk for Alcohol Dependence and Prenatal Exposure to Alcohol on Offspring Brain Morphology.

BACKGROUND: Offspring with a family history of alcohol dependence (AD) have been shown to have altered structural and functional integrity of corticolimbic brain structures. Similarly, prenatal exposure to alcohol is associated with a variety of structural and functional brain changes. The goal of this study was to differentiate the brain gray matter volumetric differences associated with familial risk and prenatal exposure to alcohol among offspring while controlling for lifetime personal exposures to alcohol and drugs. METHODS: A total of 52 high-risk (HR) offspring from maternal multiplex families with a high proportion of AD were studied along with 55 low-risk (LR) offspring. Voxel-based morphometric analysis was performed using statistical parametric mapping (SPM8) software using 3T structural images from these offspring to identify gray matter volume differences associated with familial risk and prenatal exposure. RESULTS: Significant familial risk group differences were seen with HR males showing reduced volume of the left inferior temporal, left fusiform, and left and right insula regions relative to LR males, controlling for prenatal exposure to alcohol drugs and cigarettes. HR females showed a reduction in the right fusiform but also showed a reduction in volume in portions of the cerebellum (left crus I and left lobe 8). Prenatal alcohol exposure effects, assessed within the familial HR group, was associated with reduced right middle cingulum and left middle temporal volume. Even low exposure resulting from mothers drinking in amounts less than the median of those who drank (53 drinks or less over the course of the pregnancy) showed a reduction in volume in the right anterior cingulum and in the left cerebellum (lobes 4 and 5). CONCLUSIONS: Familial risk for AD and prenatal exposure to alcohol and other drugs show independent effects on brain morphology.

Assessment of histopathological features of maculopapular viral exanthem and drug-induced exanthem.

BACKGROUND: Viral infections and drug reactions are the commonest causes of exanthems in clinical practice. Clinically, their overlapping features may pose a diagnostic challenge. Hematologic, in vitro, and drug provocation tests are either unreliable or impractical. METHODS: This was a descriptive, prospective study to assess and compare histopathological features of maculopapular viral and drug exanthem. Subjects fulfilling case definition of exanthems were included. Serum C-reactive protein (CRP) and absolute eosinophil count (AEC) were also studied. RESULTS: Skin biopsy slides of 48 cases were evaluated and AEC and CRP were performed. Both median AEC and CRP were lower in viral exanthem compared with drug exanthem. On histopathological evaluation, features such as lymphocytic exocytosis, and dermal infiltrate of eosinophils, lymphocytes and histiocytes were seen in a significantly greater number of drug exanthems. Other findings such as focal spongiosis, acanthosis, keratinocyte necrosis, basal cell damage, papillary dermal edema and atypical lymphocytes in the dermis were also observed in higher though not statistically significant number of drug exanthem biopsies. CONCLUSIONS: Certain histopathological features can help to differentiate between the two exanthems and this modality may be used in situations when there is clinical overlap and when drug rechallenge cannot be undertaken.

Assessment of Efficacy of the 595-nm Pulsed Dye Laser in the Treatment of Facial Port-Wine Stains in Indian Patients.

BACKGROUND: Pulsed dye lasers have revolutionized treatment of port-wine stains (PWS). The authors' previous study with a 585-nm/0.45-millisecond pulsed dye laser (PDL) showed 25% to 75% improvement in 60% of facial PWS. METHODS: The authors analyzed data on facial PWS treated with a 595-nm tunable PDL in Indian patients. Response was assessed subjectively on a scale of -1 to 5 (Investigator Global Assessment) by comparing pretreatment and posttreatment photographs. Patients' perception of change in PWS was also noted on a visual analog scale from 0 to 10 (Patient Global Assessment). Side effects were recorded. RESULTS: A total of 74 flat and 24 hypertrophic PWS in skin Types IV and V with a median lesion size of 56 cm and 102 cm, respectively, and color ranging from pink to purple were treated. They underwent a mean of 7.3 and 8.5 sessions (range: 4-10 session), respectively. A mean lightening of 54% in flat and 40% in hypertrophic PWS was observed. After 10 treatments, 46.6% of flat PWS cases showed >75% lightening and an equal number had 25% to 75% improvement. A >75% improvement was observed in 12.5% of hypertrophic PWS with 75% of cases showing between 25% to 75% improvement. No significant side effects were noted. CONCLUSION: The 595-nm tunable PDL produced moderate response with no significant side effects.

CaAP2 transcription factor is a candidate gene for a flowering repressor and a candidate for controlling natural variation of flowering time in Capsicum annuum.

KEY MESSAGE: The APETALA2 transcription factor homolog CaAP2 is a candidate gene for a flowering repressor in pepper, as revealed by induced-mutation phenotype, and a candidate underlying a major QTL controlling natural variation in flowering time. To decipher the genetic control of transition to flowering in pepper (Capsicum spp.) and determine the extent of gene function conservation compared to model species, we isolated and characterized several ethyl methanesulfonate (EMS)-induced mutants that vary in their flowering time compared to the wild type. In the present study, we report on the isolation of an early-flowering mutant that flowers after four leaves on the primary stem compared to nine leaves in the wild-type 'Maor'. By genetic mapping and sequencing of putative candidate genes linked to the mutant phenotype, we identified a member of the APETALA2 (AP2) transcription factor family, CaAP2, which was disrupted in the early-flowering mutant. CaAP2 is a likely ortholog of AP2 that functions as a repressor of flowering in Arabidopsis. To test whether CaAP2 has an effect on controlling natural variation in the transition to flowering in pepper, we performed QTL mapping for flowering time in a cross between early and late-flowering C. annuum accessions. We identified a major QTL in a region of chromosome 2 in which CaAP2 was the most significant marker, explaining 52 % of the phenotypic variation of the trait. Sequence comparison of the CaAP2 open reading frames in the two parents used for QTL mapping did not reveal significant variation. In contrast, significant differences in expression level of CaAP2 were detected between near-isogenic lines that differ for the flowering time QTL, supporting the putative function of CaAP2 as a major repressor of flowering in pepper.

Clinical profile and quality of life of patients with occupational contact dermatitis from New Delhi, India.

BACKGROUND: Data regarding occupational contact dermatitis (OCD) and its effect on quality of life (QOL) in India are limited. OBJECTIVES/AIMS: To evaluate patients with OCD and record the outcome of treatment. PATIENTS/MATERIALS/METHODS: All patients with OCD were evaluated for severity of disease (by the use of physician global assessment) and its effect on QOL (by use of the Dermatology Life Quality Index) questionnaire) at the first visit and after 3 months of treatment. RESULTS: Among 117 patients with OCD, hand eczema was present in 81.2%. Positive patch test reactions were found in 76%. The most common allergens were Parthenium hysterophorus and potassium dichromate. The most frequent diagnosis was occupational allergic contact dermatitis (OACD) (57%), caused by farming and construction work, followed by occupational irritant contact dermatitis (OICD) (24%), caused by wet work. Severe psychosocial distress was recorded in 62.5% of patients. After 3 months of treatment, 83% improved significantly, and 54% had improvement in QOL. CONCLUSIONS: Farmers were most frequently affected, followed by construction workers and housewives. OACD was found at a higher frequency than OICD. The most frequent allergens were Parthenium hysterophorus in farmers, potassium dichromate in construction workers, and vegetables in housewives. OCD has a significant impact on QOL. Patch testing, in addition to standard treatment, improves the outcome considerably.

Comparison of the Clinical Efficacy of Rituximab Infusion and Dexamethasone-Cyclophosphamide Pulse Therapy and Their Effect on Serum Th1, Th2, and Th17 Cytokines in Pemphigus Vulgaris-A Prospective, Nonrandomized, Comparative Pilot Study.

Background: Rituximab infusion and dexamethasone-cyclophosphamide pulse (DCP) are the two most popular regimens used in pemphigus vulgaris (PV) in India. Objective: The present study compared the clinical efficacy of rituximab and DCP in Indian PV patients and their effects on serum Th1,2, and 17 cytokine levels. Materials and Methods: A total of 37 patients received DCP (Group A, n = 22) or rituximab (Group B, rheumatoid arthritis protocol (n = 15)) as per patients' preference. They were monitored for clinical response, adverse events (AEs), changes in serum anti-desmoglein-1,3 antibody titers and Th1,2 and 17 cytokine levels at baseline and weeks 20 and 52. Results: The proportion of patients attaining disease control, remission, and relapse in groups A and B were 82% and 93%; 73% and 93%; and 27% and 50%, respectively, after a median duration of 2 months each for disease control; 4 and 4.5 months for remission; and 5 and 7 months for relapse post remission. The musculoskeletal AEs were the highest in the two groups. Significant and comparable decreases in anti-dsg1 and 3 titers from baseline to weeks 20 and 52 were observed in both groups. Th1 and Th17 cytokine levels decreased, while Th2 cytokines increased post-treatment in both groups. However, no correlation was found between change in body surface area of involvement by PV and anti-dsg titers and cytokine levels before and after therapy in both groups. Conclusion: Comparable clinical efficacy between DCP and rituximab was observed.

An Open-Label Non-Randomized Preliminary Noninferiority Study Comparing Home-Based Handheld Narrow-Band UVB Comb Device with Standard Hospital-Based Whole-Body Narrow-Band UVB Therapy in Localized Vitiligo.

Background: Narrow-band ultraviolet B (NB-UVB) is the standard therapy for vitiligo. Objective: The objective of this study is to compare the safety and clinical efficacy of a handheld NB-UVB comb device with the standard whole-body NB-UVB therapy in localized stable vitiligo. Materials and Methods: Thirty-one vitiligo patients were allocated to either daily therapy with a home-based handheld comb device (group A, n = 17) or thrice-weekly hospital-based whole-body NB-UVB therapy (group B, n = 14) for 4 months, based on their preference. The primary and secondary outcomes were assessed at each follow-up, and appropriate statistical tools were used for analysis. Results: Of the 31 patients enrolled, 26 patients (study groups A/B: 15/11) completed the study. Primary outcome: Median percentage repigmentation of the representative patch in groups A and B were 51.35% and 63.85%, respectively (P = 0.64). The median size reduction of the representative patch in both groups was statistically significant (P < 0.05). The mean difference between "per protocol analysis" and "intention to treat" showed noninferiority. Secondary outcomes: Both groups were comparable on Lund and Browder score, patient global assessment and investigator global assessment scores, adverse events, color match, and change in the quality of life. The comparison group had a significantly greater number of missed sessions (P = 0.02). The majority of patients had a "good" response in both groups. Conclusion: Handheld NB-UVB comb device daily with a fixed dose of fluence was found to be noninferior with better compliance to standard whole-body NB-UVB therapy.

Copper(ii) and cobalt(iii) Schiff base complexes with hydroxy anchors as sensitizers in dye-sensitized solar cells (DSSCs).

Two Schiff base complexes of copper(ii) and cobalt(iii) having the formulae [CuL2] (Cu-Sal) and [CoL3] (Co-Sal) (HL = 2-(((2-hydroxyethyl)imino)methyl)phenol) have been synthesized and characterized microanalytically, spectroscopically and in the case of Cu-Sal using single crystal X-ray diffraction technique. The single crystal X-ray analysis reveals a square planar geometry around Cu(ii) satisfied by phenoxide oxygen and imine nitrogen of the L- ligand to generate a six membered chelate ring. The solid state structure of Cu-Sal is satisfied by varied intermolecular non-covalent interactions. The nature of these interactions has been addressed with the aid of Hirshfeld surface analysis. Both compounds have been used as sensitizers in TiO2 based dye sensitized solar cells (DSSCs) and the DSSC experiments revealed that Co-Sal offers better photovoltaic performance in comparison to Cu-Sal. The Co-Sal exhibited a J sc of 9.75 mA cm-2 with a V oc of -0.648 V, incident photon to current conversion efficiency (IPCE) of 57% and η of 3.84%. The relatively better photovoltaic performance of Co-Sal could be attributed to better light absorption and dye loading than that of Cu-Sal.

Oral Propranolol Therapy for Infantile Hemangioma: Long-term Follow-up.

ß-blocker therapy is currently the treatment of choice for infantile hemangiomas (IH), albeit with limited data on long-term treatment outcomes. Herein, authors treated 67 IH lesions in 47 patients with oral propranolol at 2 mg/kg/d for a median of 9 mo and followed them up for a median of 48 mo. While no maintenance therapy was required for 18 lesions (26.9%), the rest needed maintenance therapy. Both treatment regimens had comparable efficacy (83.3±23.9% and 92.0±13.8%) but chances of IH recurrence was higher in lesions requiring maintenance therapy. Also, patients treated at ≤5 mo of age had a significantly better response and a lower recurrence rate than patients treated at >5 mo of age (95.0±7.9% vs. 87.0±17.5%, p = 0.05). Authors' experience suggests that longer durations of maintenance therapy offered no added advantage to the overall improvement of IH while treatment initiation at an earlier age showed better improvement and lower recurrence rates.

An aetiological & clinicopathological study on cutaneous vasculitis.

BACKGROUND & OBJECTIVES: Cutaneous vasculitis has protean clinical manifestations. It may be idiopathic or associated with a spectrum of conditions such as infections, drugs, etc. Skin is involved in both small vessel vasculitis (SVV) and medium vessel vasculitis (MVV). Overlapping features are seen between SVV and MVV. The histopathological features may not always relate with the clinical lesions. The aim of the present study was to evaluate the aetiological factors and clinicopathological association in patients with cutaneous vasculitis. METHODS: In this cross-sectional study, detailed history and clinical examination were done on patients with biopsy proven cutaneous vasculitis. Two skin biopsies were taken from each patient for routine histopathology and direct immunofluorescence. RESULTS: Of the 61 patients studied, hypersensitivity vasculitis (HSV) [23 (37.7%)] and Henoch Schonlein purpura (HSP) [16 (26.2%)] were the two most common forms. Systemic involvement was seen in 32 (52.45%) patients. Drugs were implicated in 12 (19.7%) cases, infections in 7 (11.4%) and connective tissue disorders in 4 (6.5%) cases. Histologically SVV was the most common pattern, seen in all the clinically diagnosed patients with SVV (47), and in 12 of the 14 clinically diagnosed patients with MVV. Direct immunofluorescence showed positivity for at least one immunoreactant in 62 per cent of the patients and the most common deposit was C3 followed by IgG, IgA and IgM. INTERPRETATION & CONCLUSIONS: Majority of our patients with cutaneous vasculitis were idiopathic. Histologically, SVV was seen in most of our patients. No association was seen between history of drug intake and tissue eosinophilia and also between histologically severe vasculitis and clinical severity. The presence of immunoreactant IgA was not specific for HSP.