Non-arteritic anterior ischaemic optic neuropathy and obstructive sleep apnoea.

Anterior ischaemic optic neuropathies (AIONs) are a common cause of permanent visual loss in the elderly population. The non-arteritic subtype has been intensively studied. While systemic associations such as hypertension and diabetes mellitus are commonly recognized and treated, others such as obstructive sleep apnoea (OSA) are largely overlooked in daily practice. A 60-year-old man who gave no history of any systemic illness presented to us 1 week following an uneventful cataract surgery with posterior chamber intraocular lens implantation in his right eye. The surgery was performed elsewhere by an eye-healthcare professional where the patient presented primarily with a history of progressively worsening diminution of vision in the same eye for 5 days and was diagnosed with a senile cataract. The postoperative visual gain was unsatisfactory; hence he sought another opinion. A diagnosis of non-arteritic AION (NAION) was established. Systemic evaluation revealed elevated diastolic blood pressure, dyslipidaemia and severe OSA. Prompt treatment with systemic steroids and simultaneous management of the accompanying systemic morbid conditions saved some useful vision in the affected eye. This also prevented involvement of the fellow unaffected eye. A comprehensive ocular examination with emphasis on systemic evaluation of the patient for coexisting illness is imperative before proceeding with any medical or surgical intervention. OSA is a definitive risk factor for the development of NAION, though it remains underdiagnosed and untreated. Cataract surgery has been shown to worsen underlying NAION. Systemic stabilization averts potentially blinding sequel in the unaffected eye of these patients.

Epidermal growth factor receptor mutations in adenocarcinoma lung: Comparison of techniques for mutation detection.

Background: Targeted therapy using tyrosine kinase inhibitors in cases of non-small-cell lung carcinoma (NSCLC) that harbor epidermal growth factor receptor (EGFR) mutations has drastically improved the overall survival rate. The current study estimated the frequency of EGFR mutations in the Indian population by analyzing the diagnostic parameters of various techniques available for the detection of these mutations. Materials and Methods: A case series of 100 histologically diagnosed and immunohistochemically confirmed NSCLC with the adenocarcinoma phenotype comprises the study sample. EGFR mutations were detected using clone-specific immunohistochemistry (IHC), real-time polymerase chain reaction (PCR), and Sanger sequencing. Results: EGFR mutations were identified in 48% cases with 72.78% mutations involving exon 19. Clone-specific IHC had a low sensitivity of 46.43%, and the specificity was 79.17%. Sanger sequencing yielded interpretable results in 16% cases only, which were in concordance with the results of real-time PCR. Conclusion: EGFR mutations are increasingly being explored for targeted therapy and personalized medicine. Real-time PCR was found to be the best and the most accurate method for the detection of somatic EGFR mutations in adenocarcinoma primarily in the lungs.

Aggressive oral granular cell tumor with periorbital involvement: An unusual case.

Granular cell tumor (GCT) of the oral cavity is rare and so is the involvement of the eye, orbit, and ocular adnexa. A 65-year-old male developed a posttraumatic ulceroproliferative mass over his left cheek for the past 1 year. The mass involved the periorbital region with accompanying blood-stained purulent discharge from multiple sinus tracts over this lesion for the past 6 months. Radiographs of the orbit suggested chronic osteomyelitis. The lesion was not responsive to treatment with antibiotics. Enlarged submandibular lymph node demonstrated reactive lymphadenitis on cytological examination. However, computed tomography scan of the paranasal sinus (PNS) revealed possibly a malignant mass extending into the maxillary sinus and left extraconal space. Surprisingly, histopathological examination and immunohistochemistry from a growth involving the left upper retromolar region that extended up to the midline and periorbital region suggested a diagnosis of GCT. This unusual and new presentation of GCT is not well known to the dentists and also to the ophthalmologists. It is imperative to examine anatomically neighboring structures, especially the eye, nasal cavity, PNSs, and oval cavity among other structures in an underlying pathology in either of these sites.

Spectrum of interstitial lung diseases and their association with pulmonary hypertension.

Interstitial lung diseases (ILDs) are an intriguing group of pulmonary disorders, which still require the study of epidemiological, genetic, pathophysiological, clinical, and radiological parameters. Pulmonary hypertension (PH) is an underreported complication in interstitial lung diseases which is associated with worse outcome. In our study, we have reported the spectrum of ILDs and estimated the prevalence of pulmonary hypertension among these subjects at a tertiary care centre. A cross-sectional study was performed in which demographical, clinical, radiological, and histological data of subjects with ILD, attending the department of Respiratory Medicine in the University was collected from 1st September 2018 to 31st August 2019. Serological tests were done wherever indicated. Standard criteria along with multidisciplinary opinion were needed to arrive at the final diagnosis. All subjects were screened for pulmonary hypertension via 2-D echocardiography. Mean pulmonary artery pressure ≥20 mmHg was used to define PH. In the defined period, 239 subjects were enrolled (58% females, n=141; mean age 52.38±13.40 years). A tissue diagnosis was obtained in 34% cases.  The most common ILD was hypersensitivity pneumonitis (32.2%), followed by autoimmune-ILD (31.4%), idiopathic pulmonary fibrosis (IPF) (15.9%) and sarcoidosis (12.6%), non-IPF idiopathic interstitial pneumonitis (2.1%) and rest 21 (5.9%) subjects were diagnosed as other types of ILD.  Pulmonary hypertension was seen in 46.0% of subjects.

Hospital-based study on demographic, hematological, and biochemical profile of lung cancer patients.

BACKGROUND: Lung cancer is considered as the most commonly diagnosed cancer. It is the leading cause of cancer-related mortality. Smoking and environmental pollutants act as important risk factors in majority of lung cancer cases (80%-90%). MATERIAL AND METHODS: This is a hospital-based study carried on in lung cancer patients of North India. Demographic profile of lung cancer patients was recorded. Hematological and biochemical profiles of lung cancer patients and healthy controls were compared. RESULTS: Highest proportion of lung cancer was found in the age group of 46-60 years. Lung cancer was seen in highest number in male gender (76.63%) and also in those patients belonging to the rural category (84.58%). In this study, only 3.98% lung cancer patients having the past history of cancer and 5.47% showing the family history of cancer. Significant differences were found in weight and body mass index (BMI) of lung cancer patients when compared to healthy control (P < 0.0001). Hemoglobin (Hb) was found lower in lung cancer patients as compared with healthy controls. Significant difference was also observed in Hb levels of these two groups (P < 0.000). The serum protein level was lower in lung cancer patients than healthy controls. A significant difference was also observed in the protein levels of these two groups (P < 0.0001). Serum alkaline phosphatase (ALP) levels were higher in lung cancer patients in comparison to healthy controls. A significant difference was also observed in serum ALP levels in lung cancer patients as compared with healthy controls (P < 0.0001). CONCLUSIONS: Significant difference between BMI, Hb, serum albumin, and total protein was found in this study. These biomarkers may be helpful in the diagnosis of lung cancer at early stage and also in the follow-up assessment of the effects of treatment.

Extra-central nervous system tuberculosis in HIV-uninfected patients of tuberculous meningitis: A prospective evaluation.

OBJECTIVE: Disseminated tuberculosis is characterized with involvement of two or more non-contiguous sites. In this work we evaluated patients of tuberculous meningitis for possible extra-central nervous system tuberculosis. METHOD: This prospective observational study was performed at a tertiary care institute in Northern India. We included consecutive HIV-uninfected cases of TBM. Patients were evaluated for extra-central nervous system (CNS) tuberculosis. We focussed on peripheral lymph nodes, chest, abdomen, and spinal involvement. All patients were subjected to MRI brain and spine. Patients were also subjected to CT thorax and abdomen. Enlarged lymph nodes, if present, were biopsied. Ascitic and pleural fluid were subjected to biochemical, cellular analysis as well as cartridge-based nucleic acid amplification test (CBNAAT) for detection of Mycobacterium tuberculosis and rifampicin resistance. RESULTS: We enrolled 110 patients of TBM. After cerebrospinal fluid examination alone, 14 (12.7%) patients had microbiologically-confirmed TBM. After planned work-up for extra CNS tuberculosis, 5 additional cases were microbiologically confirmed. Similarly, before work-up for extra CNS tuberculosis, 29 (26.4%) patients were categorized as probable TBM. The number of probable cases increased to 72 (65.5%) (P<0.001) with identification of tuberculosis elsewhere. Lung (83.6%) was the most involved site. Abdominal tuberculosis was noted in 29 (26.4%) patients. On imaging spine, 17 (15.5%) patients demonstrated presence of spinal tuberculous. Lymph adenopathy recorded in 2 cases. Lymph node biopsy revealed tuberculous granuloma in both the cases. All 7 patients, who died, had disseminated tuberculosis. CONCLUSION: Extra CNS tuberculous involvement is common in TBM. Search for extra CNS tuberculous enables upgrading diagnostic accuracy.

Kirsten rat sarcoma virus protein overexpression in adenocarcinoma lung: Association with clinicopathological and histomorphological features.

CONTEXT: Lung cancer is the leading cause of cancer-related deaths worldwide. The constitutive activation of multiple signaling pathways is the major cause of carcinogenesis. AIMS: The study evaluates the frequency of Kirsten rat sarcoma virus (KRAS) protein overexpression and correlates with clinicopathological and histomorphological features in non-small cell lung carcinoma (NSCLC)-adenocarcinoma. SETTINGS AND DESIGN: Tertiary hospital-based retrospective and prospective case series included 100 cases of NSCLC-adenocarcinoma. MATERIALS AND METHODS: The basic panel of Immunohistochemistry including Napsin-A, thyroid transcription factor-1 (TTF-1), and markers for squamous differentiation, p-40 was used in formalin-fixed paraffin-embedded tissue blocks. The KRAS monoclonal antibody (9.13, Thermo Fisher Scientific, USA) was used. STATISTICAL ANALYSIS USED: The IBM-Statistical Package for the Social Sciences (SPSS) (SPSS, International Business Machines Corporation, New York, NY, USA) analysis software, version 16 was used for all statistical calculations. RESULTS: KRAS protein expressed in 28.0% (28/100) cases. Cases were grouped as KRAS positive and negative. TTF-1 and Napsin-A were expressed in 89.25% (n = 25) and 92.86% (n = 26) cases, respectively. Stage IV clinical disease was identified in 55% of cases, and 36.84% of cases had a mean survival between 6 and 12 months. In KRAS positive group, the most common pattern of cellular arrangement was acinar/loose clusters pattern present in 64.29% (n = 21) and 75.0% (n = 18) cases followed by the solid pattern present in 42.86% of cases (n = 12), respectively. Necrosis was identified in 57.14% (n = 16) cases. Mucin pattern was present in 32.14% of cases (n = 9), which was significantly different when compared with the KRAS negative group (P = 0.036). CONCLUSIONS: This finding may imply that KRAS mutations may not be entirely triggered by alterations induced by carcinogens in smoke. KRAS gene is frequently mutated in pulmonary tumors. It should be tested in NSCLC owing to its predictive and prognostic effects.

Association of inflammatory biomarkers with lung cancer in North Indian population.

BACKGROUND: Lung cancer is characterized by uncontrolled cell growth of the lung tissues. It is the leading cause of cancer-related deaths worldwide. OBJECTIVES: The study aimed to determine the circulating CRP, TNF-α, IL-6 and IL-8 levels in lung cancer and healthy control and also established association between these biomarkers with the smoking status as well as the stages of the disease. METHODOLOGY: 51 lung cancer patients and 51 healthy controls were enrolled in this case-control study. The serum levels of CRP, TNF-α, IL-6 and IL-8 were measured in lung cancer patients and healthy control groups. RESULTS: The levels of serum CRP, TNF-α, IL-6 and IL-8 were significantly higher in lung cancer patients when compared with controls(P<0.0001). The levels of these biomarkers were also significantly higher in stage iii/iv as compared to stage i/ii(P<0.001). Significant difference in the levels of these biomarkers were also found in smoker and non-smoker lung cancer patients as compared to controls(P<0.001). CONCLUSION: CRP, TNF-α, IL-6 and IL-8 are the promising biomarkers in the identification of lung cancer patients. The study also supports the association of inflammatory markers to lung cancer risk. Hence these findings suggest the levels of these biomarkers could be a useful tool for guiding the diagnosis of lung cancer.

Computer Algorithms in Assessment of Obstructive Sleep Apnoea Syndrome and Its Application in Estimating Prevalence of Sleep Related Disorders in Population.

The incorporation of telemedicine and artificial intelligence for early screening and assessment of severity of life-style disorders has a great potential for better assessment in a busy outpatient clinic and thereby curtail down the related morbidities. A computer based algorithm based upon standardized questionnaire (from established assessment tools) is designed to assess the risk of obstructive sleep apnoea syndrome (OSAS). In addition the incorporation of basic screening questions of anamnesis help in suggesting a probable diagnosis of sleep related disorder as well. The overall data at our center has been analyzed to establish the existing pattern of sleep related disorders. Of 850 healthy subjects screened, prevalence of snoring was 20.47% while OSAS was seen in 4.20% (N = 25) in males and 2.64% (N = 8) in females. The parasomnia was most prevalent (14.71%), followed by insomnia (10.24%), periodic leg movement (6.59%), bruxism (1.65%) and narcolepsy (0.59%). Hypertension, laryngopharyngeal reflux and obesity were the common co-morbidities in OSAS while family history of hypertension and diabetes were common in snorers. A significant association with OSA was seen with diabetes mellitus, neck circumference and nasal obstruction, while, obesity and apnoeic episodes were more significantly associated with OSA than snorers. Increased waist to hip ratio was appreciated in both the OSAS and snorers. The algorithm based online assessment is likely to diagnose the occult clinical cases as well as assess the risk of OSAS. In routine outpatient clinic, a clinician may better assess the patient morbidity with a comprehensive availability of symptoms and moreover enhance the post-treatment compliance. In addition a smartphone based computerized assessment for general population may be designed for other lifestyle disorders as well.

ROS-1 re-arrangements and c-MET amplifications in adenocarcinoma lung: A tertiary care center study from North India.

BACKGROUND: C-ros oncogene 1, receptor tyrosine kinase (ROS 1) proto-oncogene 1, receptor tyrosine kinase (ROS-1) fusions are potent oncogenic drivers and these re-arrangements promote signal transduction programs leading to uninhibited cell survival and proliferation identified in 1-2% of cases of nonsmall-cell lung cancer. Mesenchymal epithelial transition factor (MET) receptor tyrosine kinase and its ligand are predominantly involved in epithelial mesenchymal transition and tissue regeneration. The MET amplification and overexpression is oncogenic in 3-7% cases. The objectives of this study were to identify the frequency of ROS-1 and c-MET protein expression in adenocarcinoma lung and to correlate it with the clinicopathological parameters and to analyze the histomorphology of cases that harbor the characteristic mutations (c-MET and ROS-1). MATERIALS AND METHODS: Study group comprised a prospective cases series of 90 cases of adenocarcinoma lung. ROS-1 protein expression was determined by immunohistochemistry using the D4D6 rabbit monoclonal antibody (Cell Signaling, Danvers, MA) and c-MET protein expressed was analyzed using the SP-44 clone (Ventana Medical Systems). RESULTS: c-MET protein expression was identified in 33.33% cases (n = 30/90) with statistically significant thyroid transcription factor-1 (TTF-1) positivity. ROS-1 protein expression was detected in 3.33% cases (n-3/90), in biopsies from the respiratory tree with TTF-1 expression. CONCLUSION: This is the first study from the Indian subcontinent to identify the frequency of ROS-1 re-arrangements and MET amplification in the Indian population. The availability of targeted therapy that has a significant impact on survival makes it essential to detect these less frequent mutations.

Serum procalcitonin levels in chronic obstructive pulmonary disease patients in North Indian Population.

Background: Exacerbations in Chronic obstructive pulmonary disease (COPD) have a considerable impact on morbidity, mortality, and quality of life. Procalcitonin (PCT) a polypeptide normally produced in neuroendocrine cells of the thyroid and lungs is a marker of systemic inflammation and bacterial infection. Objectives: The aim of this study was to determine the levels of PCT in serum of acute exacerbation of COPD patients (AECOPD) and stable COPD patients in North Indian population. Materials and Methods: The study was conducted on 80 AECOPD and 80 stable COPD patients in respiratory medicine department at tertiary care hospital in north India. PCT levels were measured in serum by ELISA kit. GraphPad Prism version 6.01 (GraphPad software Inc.; La, Jolla, CA, USA) was used for analysis of data. Results: The present study showed that mean serum PCT levels were significantly higher in AECOPD group (1.31 ± 0.79) as compared to stable COPD group (0.1 ± 0.09) (P < 0.001). Conclusion: The study confirms that PCT levels were higher in AECOPD patients as compared to stable COPD patients. PCT could be used as a biomarker of exacerbations of COPD and can be used to target management and guiding the treatment in patients with acute exacerbations of COPD.

RésuméIntroduction: Maladie pulmonaire obstructive chronique (MPOC), une maladie évolutive maladie pulmonaire caractérisée par une atteinte pulmonaire et systémique l'inflammation, est devenu un important et croissant santé mondiale problème qui est prédit pour être une troisième cause la plus commune de Décès et invalidité d'ici 2020.[1] Le fardeau mondial de la maladie Une étude rapporte une prévalence de 251 millions de cas de MPOC globalement en 2016. On estime que 3,17 millions de décès ont été enregistrés causée par la maladie en 2015 (soit 5% de tous les décès dans le monde. Contexte: Les exacerbations de la maladie pulmonaire obstructive chronique (MPOC) ont un impact considérable sur la morbidité, la mortalité et qualité de vie. La procalcitonine (PCT), un polypeptide normalement produit dans les cellules neuroendocrines de la thyroïde et des poumons, est un marqueur de la inflammation et infection bactérienne. Objectifs: Le but de cette étude était de déterminer les taux de PCT dans le sérum de l'exacerbation aiguë de Patients BPCO (AECOPD) et patients BPCO stables dans la population de l'Inde du Nord. Matériels et méthodes: L'étude a été menée sur 80 AECOPD et 80 patients BPCO stables dans le département de médecine respiratoire d'un hôpital de soins tertiaires dans le nord de l'Inde. Les niveaux de PCT ont été mesurés en sérum par kit ELISA. La version 6.01 de GraphPad Prism (logiciel GraphPad Inc .; La, Jolla, Californie, États-Unis) a été utilisée pour l'analyse de données. Résultats: La présente étude a montré que les taux sériques moyens de PCT étaient significativement plus élevés dans le groupe AECOPD (1,31 ± 0,79) par rapport à une MPOC stable. groupe (0,1 ± 0,09) (p <0,001). Conclusion: l'étude confirme que les taux de PCT étaient plus élevés chez les patients AECOPD que chez ceux atteints de MPOC stable. les patients. La PCT pourrait être utilisée comme biomarqueur d'exacerbations de la MPOC et pourrait être utilisée pour cibler la prise en charge et guider le traitement patients présentant une exacerbation aiguë de la MPOC.

Atypical carcinoid tumor of the lung: A rare entity.

Carcinoids account for approximately 2% of all lung tumors, and the atypical carcinoids (ACs) are much rarer than typical carcinoid. Here, we report a rare case of AC tumor of the lung. A 50-year-old female patient presented with left-sided chest pain for 1 year, cough for 6 months, and loss of appetite for 6 months. Contrast-enhanced computed tomography scan of the thorax revealed an ill-defined heterogeneously enhancing soft-tissue attenuation lesion in the mediastinum following which transthoracic biopsy was done. Histomorphology and immunohistochemistry were consistent with AC, a neuroendocrine tumor. Combination chemotherapy consisting of cisplatin and etoposide was administered as initial chemotherapy.

A Comparative Study of Cell Block versus Biopsy for Detection of Epidermal Growth Factor Receptor Mutations and Anaplastic Lymphoma Kinase Rearrangement in Adenocarcinoma Lung.

BACKGROUND: Lung cancer is a leading cause of deaths attributed to cancer worldwide. Epidermal growth factor receptor (EGFR) mutation and anaplastic lymphoma kinase (ALK) rearrangement are commonly found in patients of adenocarcinoma lung against, which targeted therapy is available. In this era of personalized medicine, it is a rationale to detect these molecular alterations in cases of lung carcinomas. AIMS: The objectives were to compare the diagnostic efficacy of cytological samples for the detection of EGFR and ALK protein expression using immunocytochemistry in nonsmall cell lung carcinoma. MATERIALS AND METHODS: We compared 22 cell blocks and biopsies for the detection of EGFR and ALK protein expression by immunohistochemistry (IHC). EGFR IHC was performed using EGFR Receptor (E746-A750 del Specific) (6B6) monoclonal antibody and ALK IHC was done using Ventana anti-ALK (D5F3) monoclonal primary antibody. RESULTS: Two cases were found to be positive; 20 cases were negative for EGFR IHC both in biopsies and cell blocks. ALK IHC was positive in one case; negative in 21 cases. The results of IHC were also concordant for biopsies and cell blocks. The sensitivity and specificity were 100% for immunocytochemical detection of ALK and EGFR in cell blocks with respect to biopsies. CONCLUSION: We conclude that cell blocks can serve as a potential substitute for biopsies for detection of EGFR and ALK protein by immunocytochemistry, whenever patient presents with effusion and biopsy cannot be done or when tissue is not adequate.

Detection of Anaplastic Lymphoma Kinase Gene Re-Arrangement in Non-Small Cell Lung Carcinoma in the Indian Population: Comparison of Techniques and Immunohistochemistry Clones.

OBJECTIVE: Predictive and prognostic markers have revolutionized personalized therapy in non-small cell lung carcinoma (NSCLC). Crizotinib is now approved for locally advanced or metastatic NSCLC that is anaplastic lymphoma kinase (ALK) positive by either Fluorescence in situ hybridization (FISH) or immunohistochemistry (IHC). The current study aimed to detect the incidence of ALK gene re-arrangement in the Indian population, to compare the various IHC antibodies with FISH as a gold standard, and to analyze the morphology of cases with ALK phenotype. MATERIAL AND METHOD: A case series of 614 cases of NSCLC were included. IHC for detection of ALK phenotype was compared with FISH using 5A4 clone (Labvision, USA), ALK-1(Dako, Denmark) and D5F3 clone (Ventana, USA). RESULTS: ALK gene rearrangement was evident in 4.07% of the cases. Cases with ALK phenotype had unique histomorphology with presence of mucin or signet ring cells in association with necrosis, high tumour grade and poor differentiation. Comparison of various antibody clones used in IHC revealed that the sensitivity and specificity using the D5F3 clone (100%, 100%) and 5A4 clone (87.5%, 100%) were similar while the ALK-1 clone had the lowest sensitivity and specificity (50%, 95.5%). CONCLUSION: The incidence of ALK gene rearrangement in NSCLC in the current Indian study is within the worldwide reported range of 3-5%. This is the first study from the Indian subcontinent to compare various IHC antibodies used for detection of ALK phenotype. IHC using D5F3 clone and 5A4 clone may be considered as a rapid reliable and inexpensive method for detection of ALK gene rearrangement.

Leser-Trélat Syndrome in a Male with Breast Carcinoma and Eyelid Basal Cell Carcinoma.

PURPOSE: Leser-Trélat syndrome consists of appearance of a solid tumor-like carcinoma breast, colon, or stomach following eruption of multiple seborrheic keratoses (SK) of the skin. We present an unusual and possibly the first case report of Leser-Trélat syndrome in a male patient with a history of mastectomy for breast carcinoma who presented to us with a second malignancy in the form of basal cell carcinoma (BCC) of the lower eyelid. PROCEDURE: A 75-year-old male presented in 2014 with a history of modified radical mastectomy for infiltrating ductal carcinoma of the left breast which was performed 11 years prior to the day of presentation. Breast carcinoma was diagnosed following eruption of multiple SK at the same time. In the previous 3 years he noted a nodulo-ulcerative growth over the lateral aspect of the right lower eyelid which was clinically diagnosed as BCC. Mass excision under frozen section control and lid reconstruction was performed. Diagnosis of BCC was confirmed on histopathological examination of the excised specimen. RESULTS AND CONCLUSIONS: Though a previously unobserved entity, our case supports the importance of Leser-Trélat sign and its relevance to affected individuals, as early recognition and prompt treatment of a low-stage cancer offers good prognosis.

Stenotrophomonas maltophilia: An emerging entity for cluster endophthalmitis.

PURPOSE: This was a study of acute cluster endophthalmitis along with clinical features, culture results, and visual outcomes of 10 eyes of 10 patients after intravitreal injection of Avastin (bevacizumab) in one sitting from a single vial. METHODS: Retrospective review of intravitreal injection of 1.25 mg/0.05 ml bevacizumab that was given to 10 eyes of 10 patients on the same day from a freshly opened vial. All patients manifested with endophthalmitis the next day. Vitreous tap for direct smear and culture was done. Intravitreal antibiotics and steroids were injected and appropriate treatment begun. The injection vial of the same batch was sent for VITEKTM identification and antimicrobial susceptibility of isolates. RESULTS: Endophthalmitis presented within 24 h of intravitreal injection. There was a remarkable absence of posterior pupillary synechia. Two cases were culture-positive (20%), showing pseudomonoid growth. The vial of the same batch revealed a pseudomonoid bacilli Stenotrophomonas maltophilia using VITEKTM, which was resistant to multiple drugs. Hence, the contaminated vial was identified as the source of infection in our case. Among 10 patients, two underwent pars plana vitrectomy. Visual acuity returned to preendophthalmitis levels in 9/10 eyes after 1 month. One patient was lost to follow-up. Late complications included retinal detachment in one case and neovascular glaucoma in another. CONCLUSION: Early recognition and treatment are key factors in improving outcomes. Causative etiology could be microbial contamination of the drug vial. S. maltophilia should be considered a pathogenic organism of postintravitreal endophthalmitis.

Clinical Predictors of Streptomycin-Vestibulotoxicity.

The Global tuberculosis control is challenged with a growing resistance to antitubercular treatment (ATT) culminating in resistant (MDR/XDR) strains; an important factor being premature withdrawal of streptomycin owing to its morbidity particularly nephrotoxicity and cochleotoxicity as guidelines for their prevention exist. An attempt is made here to address the least recognized and most debilitating vestibular toxic effects of streptomycin and defining a vestibular-protocol for its early detection and progression. Thirty two prospective patients (treatment-failures, relapse and default cases) undergoing ATT (24 shots of IM streptomycin 15-20 mg/kg over 8 weeks) underwent complete vestibular workup including vestibulo-ocular and vestibulo-spinal reflex assessment with an attempt to closely follow them. Four categories (I: No-, II: Occult-, III: Delayed-Manifest- and IV: Manifest-vestibulotoxicity) were defined. The DHI and casual gait abnormality clearly differentiated III/IV from I/II. The occilopsia and head thrust tests significantly differentiated II from I. Rotation and bithermal calorics significantly differentiated I from II and II from III/IV. The Fukuda, Rhomberg, Tandem-Rhomberg and CTSIB were significant in differentiating I from II and II from III/IV. Dix-Hallpike and Positional tests were of no significance in the entire study. The Occilopsia and Head-Thrust tests that showed 100 % positivity for II to IV are more likely to better predict 'manifest' or 'occult' -vestibulotoxicity while DHI and casual gait assessment may be carried out by a paramedic at a peripheral center to suspect vestibulotoxicity. Since we found absolute compliance with our series we feel that vestibulotoxicity may not be a deciding factor for termination of streptomycin provided an in-built mechanism for patient support/counseling be incorporated in management schedule.

A study to compare the diagnostic efficacy of closed pleural biopsy with that of the thoracoscopic guided pleural biopsy in patients of pleural effusion.

BACKGROUND: The diagnostic approach to exudative pleural effusion remains an underappreciated aspect of modern thoracic medicine. 15-20% of the pleural effusions remain undiagnosed. The most efficient approach to pleural exudates remains uncertain and controversial particularly if acquisition of pleural tissue is required. The clinician needs to consider various factors when confronted with the choice between closed pleural biopsy (CPB) and thoracoscopy. Hence this study was planned to compare the diagnostic efficacy of CPB and Thoracoscopic pleural biopsy (TPB). MATERIALS AND METHODS: This was a prospective interventional study in patients of exudative pleural effusion. CPB was performed by Cope's biopsy needle. Then inspection of the pleural cavity was performed by single port rigid thoracoscope (KARL, STORZ TELECAM DX II 20 2330 20) with viewing angle of zero (0) degrees and biopsy taken from the diseased or unhealthy parietal pleura. Accordingly we compared the results of CPB and TPB. RESULTS: 46 Patients underwent this study. In all 46 patients both CPB and TPB were performed. TPB was diagnostic in 36 cases (78.2%) while CPB was diagnostic only in 10 cases i.e. 21.7%. 10 (21,7%) cases remained undiagnosed. On thoracoscopic examination 30 patients were having nodularity, 25 (54.3%) were having adhesions and 20 (43.5%) were having hyperemia. 79.3% of the patients with nodularity turned out to be malignant and 71.4% of patients with adhesions and hyperemia tubercular. CONCLUSIONS: TPB has much greater diagnostic efficacy than CPB.

Correlation between clinical characteristics, spirometric indices and high resolution computed tomography findings in patients of chronic obstructive pulmonary disease.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory disease affecting the airways, leading to significant morbidity and mortality throughout the world. There is a need to have a holistic evaluation of COPD patients, other than just measuring the level of obstruction as performed by spirometry. High resolution computed tomography (HRCT) scan of thorax partly fulfills this requirement. MATERIALS AND METHODS: Fifty patients of COPD (confirmed on spirometry as per the GOLD guidelines 2014 guidelines) were enrolled, out of which 35 patients got a HRCT done. Complete clinical evaluation was done. The Philips computer program for lung densitometry was used with these limits (-800/-1, 024 Hounsfield unit [HU]) to calculate densities, after validating densitometry values with phantoms. We established the area with a free hand drawing of the region of interest, then we established limits (in HUs) and the computer program calculated the attenuation as mean lung density (MLD) of the lower and upper lobes. RESULTS: There was a significant correlation between smoking index and anteroposterior tracheal diameter (P = 0.036). Tracheal index was found to be decreasing with increasing disease severity which was statistically significant (P = 0.037). Mean upper lobe MLD was -839.27 HU, mean lower lobe MLD was -834.91 HU and the mean MLD was -837.08 HU. The lower lobes MLD were found to be decreasing with increasing disease severity. A mild linear correlation of pre forced expiratory volume in the first second (FEV1) was observed with lower lobe and total average MLD while a mild linear correlation of Post-FEV1 was observed with both coronal (P = 0.042) and sagittal (P = 0.001) lower lobes MLD. In addition, there was a linear correlation between both pre (P = 0.050) and post (P = 0.024) FEV1/forced vital capacity with sagittal lower lobe MLD. A predictive model can be derived to quantify obstruction severity (FEV1). CONCLUSION: HRCT may be an important additional tool in the holistic evaluation of COPD. HRCT can well be correlated with the spirometric and clinical features and the level of obstruction can be indirectly derived from it by measuring the MLD.