Ipsilateral renal dysgenesis or agenesis with tubulocystic anomalies of the mesonephric duct.

Tubulocystic anomalies of the mesonephric duct (MND) are a rare group of related entities with a perplexing clinical presentation. Ultrasound is a useful screening investigation, which can help identify a dysplastic kidney or point to renal agenesis and identify cystic or tubulocystic changes in the structures derived from the ureteric bud or MND. Further evaluation with MRI can help in characterisation and direct management. The presence of a dysplastic kidney or absence of a kidney should prompt further evaluation for associated ureteric abnormalities such as ectopic insertion or ureterocoele, which could lead to a diagnosis of tubulocystic anomaly of the MND. Contribution: The authors describe two cases, briefly outline the diagnostic approach and summarise the literature on management. Reporting radiologists should be aware of these entities.

A Case of Tracheitis Sicca with Obstructive Tracheal Crusting In A 7 Year Old Boy.

Tracheitis sicca is a rare condition where there is drying and crusting of tracheal mucosa which may lead to tracheal obstruction and respiratory distress. Reported here is a case of young boy, who presented with cough, cold and respiratory distress worsening over a period of 5 days. On admission the patient was administered with dexamethasone and was intubated. However, saturation was not maintained despite assisted ventilation, and multiple episodes of self extubation always presented with stridor. Hence, otorhinolaryngology reference was taken and decision was taken to perform laryngotracheobronchoscopy. Endoscopy done showed extensive crusting in the trachea causing complete obstruction of airway above the level of carina. The crusting was meticulously removed, sent for culture, and the obstruction was relieved. The patient maintained saturation after the procedure, and was ultimately extubated and discharged.

Decreased Speech Comprehension and Increased Vocal Efforts Among Healthcare Providers Using N95 Mask.

AIM: N95 masks are recommended for the healthcare providers (HCPs) taking care of patients with coronavirus disease 2019. However, the use of these masks hampers communication. We aimed to evaluate the effect of N95 masks on speech comprehension among listeners and vocal efforts (VEs) of the HCPs. MATERIALS AND METHODS: This prospective study involved 50 HCPs. We used a single observer with normal hearing to assess the difficulty in comprehension, while VE was estimated in HCPs. The speech reception threshold (SRT), speech discrimination score (SDS), and VEs were evaluated initially without using N95 mask and then repeated with HCPs wearing N95 mask. RESULTS: The use of masks resulted in a statistically significant increase in mean SRT [4.25 (1.65) dB] and VE [2.6 (0.69)], with simultaneous decrease in mean SDS [19.2 (8.77)] (all p-values < 0.0001). Moreover, demographic parameters including age, sex, and profession were not associated with change in SRT, SDS, and VE (all p-values > 0.05). CONCLUSION: Though use of N95 masks protects the HCPs against the viral infection, it results in decreased speech comprehension and increased VEs. Moreover, these issues are universal among the HCPs and are applicable to the general public as well.

Pancreatic Neoplasms: CT Evaluation of the Uncommon Presentations of Common Lesions and Common Presentations of the Uncommon Lesions!

Pancreatic masses are commonly encountered entities in radiology practice. Pancreatic ductal adenocarcinomas (PDAC) are the commonest pancreatic malignancies that typically present as infiltrative hypodense focal masses in the pancreatic head, which are hypoattenuating to the pancreatic parenchyma on pancreatic parenchymal and venous phases. However, there are various atypical imaging features of PDACs that create a diagnostic dilemma like tumor in body or tail, diffuse glandular involvement, isoattenuating tumors, cystic changes, or calcifications. Also, few relatively uncommon pancreatic malignancies like pancreatic neuroendocrine tumors, cystic pancreatic tumors, pancreatic lymphoma, and pancreatic metastases present with overlapping features. Accurate radiological characterization of pancreatic masses is important for optimal management and prognostication. Thus, it is imperative for radiologists to be aware of all the uncommon presentations of common pancreatic lesions and common presentations of uncommon pancreatic lesions to avoid erroneous interpretations and establishing the correct diagnosis.

Prevalence of Voice Disorders in Indian Female Secondary School Teacher Population-A Cross Sectional Study.

Teachers are the backbone of any civilized society as they are the keepers of knowledge, wisdom and values. Lack of infrastructure, manpower and resources makes voice the most important tool for a teacher. Teachers need to speak loudly for long periods often under unfavourable circumstances. Increased vocal effort and incorrect phonation techniques can lead to vocal fold tissue damage and vocal fold pathologies and hence voice problems producing adverse effects on teaching performance. To study the prevalence of voice disorders in Indian female secondary school teacher population. To identify the risk factors for the development of voice disorders. A multicentric, cross-sectional observational study of 200 teachers were conducted in 4 schools over a period of 2 years. Female teachers who gave consent and were willing for follow up were included in the study. Details were collected using a structured questionnaire. Subjective analysis by VHI, perceptual analysis by GRABS score, acoustic analysis and direct visualization using Hopkins 70° rigid laryngoscope were done.The prevalence of voice disorders was 18.5%. Risk factors identified were age group 41-60 years, repeated respiratory allergies, comorbidities, constitutional symptoms, increased number of years of teaching and number of lecture hours per week. VHI, GRABS, Acoustic analysis findings were consistent with Rigid Laryngoscopic finding making them effective tools in the assessment of voice.

Effective cataract surgical coverage in adults aged 50 years and older: estimates from population-based surveys in 55 countries.

BACKGROUND: Cataract is the leading cause of blindness globally. Effective cataract surgical coverage (eCSC) measures the number of people in a population who have been operated on for cataract, and had a good outcome, as a proportion of all people operated on or requiring surgery. Therefore, eCSC describes service access (ie, cataract surgical coverage, [CSC]) adjusted for quality. The 74th World Health Assembly endorsed a global target for eCSC of a 30-percentage point increase by 2030. To enable monitoring of progress towards this target, we analysed Rapid Assessment of Avoidable Blindness (RAAB) survey data to establish baseline estimates of eCSC and CSC. METHODS: In this secondary analysis, we used data from 148 RAAB surveys undertaken in 55 countries (2003-21) to calculate eCSC, CSC, and the relative quality gap (% difference between eCSC and CSC). Eligible studies were any version of the RAAB survey conducted since 2000 with individual participant survey data and census population data for people aged 50 years or older in the sampling area and permission from the study's principal investigator for use of data. We compared median eCSC between WHO regions and World Bank income strata and calculated the pooled risk difference and risk ratio comparing eCSC in men and women. FINDINGS: Country eCSC estimates ranged from 3·8% (95% CI 2·1-5·5) in Guinea Bissau, 2010, to 70·3% (95% CI 65·8-74·9) in Hungary, 2015, and the relative quality gap from 10·8% (CSC: 65·7%, eCSC: 58·6%) in Argentina, 2013, to 73·4% (CSC: 14·3%, eCSC: 3·8%) in Guinea Bissau, 2010. Median eCSC was highest among high-income countries (60·5% [IQR 55·6-65·4]; n=2 surveys; 2011-15) and lowest among low-income countries (14·8%; [IQR 8·3-20·7]; n=14 surveys; 2005-21). eCSC was higher in men than women (148 studies pooled risk difference 3·2% [95% CI 2·3-4·1] and pooled risk ratio of 1·20 [95% CI 1·15-1·25]). INTERPRETATION: eCSC varies widely between countries, increases with greater income level, and is higher in men. In pursuit of 2030 targets, many countries, particularly in lower-resource settings, should emphasise quality improvement before increasing access to surgery. Equity must be embedded in efforts to improve access to surgery, with a focus on underserved groups. FUNDING: Indigo Trust, Peek Vision, and Wellcome Trust.

Primary CNS lymphoma in Immunocompetent patients: Appearances on Conventional and Advanced Imaging with Review of literature.

Primary central nervous system lymphoma (PCNSL) constitutes about 3% of all primary brain tumors and nearly 1 to 3% of all Non Hodgkin Lymphomas. In the recent years the incidence of primary CNS lymphoma is increasing in immunocompetent patients. As PCNSL are chemosensitive as well as radiosensitive, its early and accurate diagnosis is imperative for optimal management. Contrast enhanced Magnetic Resonance Imaging (MRI) is the recommended imaging modality for PCNSL; however, contrast enhanced Computed Tomography (CE-CT) is done in cases where MRI is contraindicated. Advanced imaging techniques like DWI (diffusion weighted imaging), MRS (MR Spectroscopy), MR perfusion, DTI (Diffusion tensor imaging) are important in diagnosis and help in its differentiation from other tumors.

Olfactory and Taste Dysfunction in Indian Population with COVID-19: A Study on 300 Patients.

The novel coronavirus disease 2019 is an ongoing pandemic and a global health emergency. Since the main portal of entry for the virus is the nose, olfactory and taste dysfunction have gained attention as important symptoms in COVID-19. The primary objectives are to assess the prevalence of olfactory and taste dysfunction in patients affected with COVID-19. And to determine whether anosmia and ageusia are early predictors of COVID-19. A prospective study was conducted on 300 patients who were laboratory diagnosed cases of COVID-19 admitted in tertiary care centre and a covid care centre. A written informed consent was taken. All patients underwent olfactory and taste examination and the details were noted in a case-record proforma. The prevalence of olfactory dysfunction in COVID-19 patients was 21% and that of taste dysfunction was 26.6%. Majority of the affected individuals were males and mainly of the younger age group. These symptoms lasted for a duration of 7-9 days and 97% of the patients showed complete recovery. Acute sudden onset olfactory and taste dysfunction seems to be a useful indicator for early diagnosis of patients thus helping in early isolation, timely management of the illness and controlling the spread of the disease.

Labrune Syndrome: A Very Rare Association of Leukoencephalopathy, Cerebral Calcifications, and Cysts.

Leukoencephalopathy, cerebral calcifications, and cysts (LCC) form a very rare association which is named as "Labrune syndrome" after Labrune who reported the first case in 1996. To the best of our knowledge only eight to 10 cases have been reported in literature to date. We report a case of a 26-year-old male with onset of neurological symptoms in late adolescence (at 19 years of age) and presented with complains of continued seizures for 7 years, giddiness with imbalance, and slowly progressive motor symptoms. MRI brain revealed multiple calcifications in bilateral basal ganglia, cerebral white matter, multiple cystic lesions in the supratentorial white matter, and abnormal diffused bilateral white matter T2 hyperintensity suggesting leukoencephalopathy. Histopathological evaluation revealed prominent congested blood vessels suggestive of angiomatous changes and cystic areas suggestive of secondary gliosis.

Imaging in a Rare Case of Unilateral External and Middle Ear Anomalies Associated with Inner Ear Malformation.

External ear malformations are commonly associated with middle ear malformations due to their closely related embryogenesis. Inner ear anomalies are less consistently seen due to their independent development. Cross-sectional imaging has come to play a critical role in the workup of congenital deafness in the pediatric age group. To optimize speech and language development, early diagnosis and treatment are very crucial. Identification of these anomalies is additionally important when operative intervention is being planned because they may complicate or perhaps preclude the surgery.

Tocilizumab improves survival in severe COVID-19 pneumonia with persistent hypoxia: a retrospective cohort study with follow-up from Mumbai, India.

BACKGROUND: Cytokine storm triggered by Severe Coronavirus Disease 2019 (COVID-19) is associated with high mortality. With high Interleukin -6 (IL-6) levels reported in COVID-19 related deaths in China, IL-6 is considered to be the key player in COVID-19 cytokine storm. Tocilizumab, a monoclonal antibody against IL-6 receptor, is used on compassionate grounds for treatment of COVID-19 cytokine storm. The aim of this study was to assess effect of tocilizumab on mortality due to COVID-19 cytokine storm. METHOD: This retrospective, observational study included patients of severe COVID-19 pneumonia with persistent hypoxia (defined as saturation 94% or less on supplemental Oxygen of 15 L per minute through non-rebreathing mask or PaO2/FiO2 ratio of less than 200) who were admitted to a tertiary care center in Mumbai, India, between 31st March to 5th July 2020. In addition to standard care, single Inj. Tocilizumab 400 mg was given intravenously to 151 consecutive COVID-19 patients with persistent hypoxia, from 13th May to 5th July 2020. These 151 patients were retrospectively analysed and compared with historic controls, ie consecutive COVID-19 patients with persistent hypoxia, defined as stated above (N = 118, from our first COVID-19 admission on 31st March to 12th May 2020 i.e., till tocilizumab was available in hospital). Univariate and multivariate Cox regression analysis was performed for identifying predictors of survival. Statistical analysis was performed using IBM SPSS version 26. RESULTS: Out of 269 (151 in tocilizumab group and 118 historic controls) patients studied from 31st March to 5th July 2020, median survival in the tocilizumab group was significantly longer than in the control group; 18 days (95% CI, 11.3 to 24.7) versus 9 days (95% CI, 5.7 to 12.3); log rank p 0.007. On multivariate Cox regression analysis, independent predictors of survival were use of tocilizumab (HR 0.621, 95% CI 0.427-0.903, P 0.013) and higher oxygen saturation. CONCLUSION: Tocilizumab may improve survival in severe COVID-19 pneumonia with persistent hypoxia. Randomised controlled trials on use of tocilizumab as rescue therapy in patients of severe COVID-19 pneumonia with hypoxia (PaO2/FiO2 less than 200) due to hyperinflammatory state, are warranted.

Role of bronchoscopy and imaging in long-standing foreign body bronchus presenting as recurrent or non-resolving lower respiratory tract infection.

INTRODUCTION: A long-standing retained foreign body in the bronchus is unusual. In majority of cases, an adequate history is not obtained, the clinical picture is usually clouded by superadded pathological changes. CASE SERIES: We report three cases of long-standing foreign body in the airway who presented with recurrent lower respiratory tract infection. Examination of respiratory system revealed no significant abnormality. Chest radiograph was normal. CT scan of the chest was useful to indicate endobronchial opacity in the airway suggestive of a foreign body. The patients underwent rigid bronchoscopy under general anesthesia for successful removal of the foreign body. CONCLUSION: So the patients with non-resolving or recurrent lower respiratory symptoms in spite of medical treatment and without any obstructive findings must undergo diagnostic bronchoscopy evaluation and imaging.

An Unusual Case of a Displaced Hemodialysis Catheter Guidewire Spontaneously Coming Out of Skull.

Hemodialysis catheter insertion is a common practice for the patients with renal failure. There are several complications associated with hemodialysis catheter insertion such as infection, catheter thrombosis, malposition, or vein stenosis; however, loss of guidewire during catheter insertion with its migration is a rare complication. We report the case of a 75-year-old male with forgotten displaced guidewire which came out spontaneously from the skull in the occipital region, three years after the hemodialysis. To the best of our knowledge, this is the only case that has been reported in literature till date. We also discuss the possible causes of a retained guidewire and measure to prevent it. How to cite this article: Muthe M, Joshi A, Firke V. An Unusual Case of a Displaced Hemodialysis Catheter Guidewire Spontaneously Coming Out of Skull. Indian J Crit Care Med 2020;24(6):480-482.

Role of MRI in Evaluation of Spectrum of Liver Lesions in Cirrhotic Patients.

MRI provides better intrinsic soft-tissue contrast with more enhanced depiction of even subtly different tissue properties making lesion evaluation easy. Faster sequences which capture arterial sequences better, lack of ionizing radiation and simultaneous evaluation of background liver parenchyma and the liver lesions are additional advantages of using MRI as the imaging technique of choice. Comprehensive liver imaging using MRI now includes T1, T2-weighted imaging and in- and opposed-phase, in addition to dynamic post-contrast imaging with proper breath holding techniques. Wider variety of liver specific contrast agents is available for use in MR imaging with the gadolinium based agents being considered the most useful and practical, particularly for lesion characterization. AIMS AND OBJECTIVES: To evaluate MRI spectrum of liver lesions in cirrhotic patients, Role of MRI in focal liver lesion evaluation and to differentiate benign versus malignant lesions. MATERIALS AND METHODS: A prospective study of OPD or IPD patients who underwent imaging tests like Ultrasonography, or CT scan for suspected chronic liver disease was done. A total 35 patients were investigated (June 2014 - November 2016) with MRI abdomen done with the patient in supine position on a Philips Achieva 3.0T MRI scanner. Standard MRI abdomen protocol, including T2W TSE in axial and coronal plane, T2W fat suppressed (SPAIR) images in axial and coronal plane, T1W TFE, in- and out-of-phase imaging and Diffusion-weighted imaging (DWI) in axial plane along with pre-contrast baseline fat-suppressed T1W imaging in at least one plane was acquired. Breath-holding was required in few sequences. 0.1 mmol/kg Gadolinium based contrast (Gadobenate) was injected at the rate of 2.5 ml/sec followed by saline flush and dynamic contrast enhanced MRI (DCE-MRI) with post-contrast fat-suppressed T1W imaging was acquired. RESULTS AND CONCLUSIONS: In cirrhosis, there is development of nodules which are initially only microscopically detectable. With progression of cirrhosis, there is development of radiologically detectable regenerative nodules, dysplastic nodules and hepatocellular carcinoma. Amongst these regenerative nodules are completely benign lesions whereas dysplastic nodules, though benign, are considered premalignant; and hepatocellular carcinoma is a malignant condition. Differentiation of benign versus malignant lesions is possible on the basis of enhancement pattern in dynamic contrast enhanced MRI. The signal characteristics of focal lesions and other findings like portal vein thrombosis are helpful, give additional clue to the diagnosis and also helpful in assigning LIRADS grade to a lesion. Also, MRI characterization after gadolinium based contrast injection was found to be similar to the previous imaging based on non-gadolinium contrast agents.

"AIR LEAK SYNDROME": An Unusual Presentation of Foreign Body in the Airway.

Spontaneous onset pneumomediastinum, pneumothorax and subcutaneous emphysema are rare presentations of a foreign body in the airway. The possible mechanism for unexplainable and non traumatic subcutaneous emphysema can be attributed to "Air leak syndrome" following inhalation of foreign body in the airway.

Respiratory epithelial adenomatoid hamartoma: a diagnostic challenge in sinonasal lesions.

Respiratory epithelial adenomatoid hamartoma (REAH) is a rare lesion in nasal cavity first reported by Wenig and Heffner in 1995. Most commonly seen in men in third to ninth decade of life. Majority of cases presents as a polypoidal mass in one or both nasal cavities. We experienced such a case of REAH originating from the nasal septum, in posterior aspect, treated by endoscopic approach. It is important to differentiate REAH from other sinonasal pathologies like inverted papilloma and low grade sinonasal adenocarcinoma. Complete surgical resection is the treatment of choice.

Role of 3T MRI in Evaluation of Bone Marrow Changes in Spine in Various Diseases.

ABSTRACT: Multiplanar MR imaging provides excellent spatial and contrast resolution necessary to differentiate the signal intensities of fatty (yellow) marrow elements from hematopoietic (red) marrow elements and hence it is useful for evaluation of various pathologies of bone marrow. Utilization of typical imaging features on conventional MR imaging techniques and other newer imaging techniques, such as diffusion-weighted imaging (DWI) and in- and out-of-phase MRI, for better characterisation of bone marrow pathologies has been highlighted. AIMS AND OBJECTIVES: To determine the prevalence of various bone marrow pathologies in spine. To study the MRI signal changes of bone marrow in various lesions such as anaemia, leukaemia, lymphomas and various bone marrow disorders. MATERIALS AND METHODS: A total of 100 patients who were investigated between November 2012 and October 2014 were included. MRI spine studies were done on a 3.0 Tesla Philips Achieva Medical Systems. OBSERVATIONS AND RESULTS: In our study, out of 100 cases studied for various spinal pathologies, 48 patients were male and 52 were female indicating almost equal male to female distribution. Maximum cases were degenerative with most common site of involvement being lumbar followed by cervical region. There were only 3 cases of depletion disorder and no case with deposition disorder. The mean age group was 45.37 years, with the range being 9 years to 72 years. Maximum patients (n = 67) were found in the age group of 41-60. CONCLUSION: Various bone marrow disorders were classified and evaluated separately. A systematic approach to its evaluation by categorization is essential with prudent use of both conventional and problem-solving techniques, such as CSI and DWI, for accurate diagnosis and appropriate patient management. Conventional radiology depicts changes of an altered bony matrix while MRI displays changes at a cellular level and is well suited for imaging the bone marrow. MRI serves as a screening method in bone marrow disorders and the diagnosis is established in context with the clinical findings or by biopsy.

Management of Difficult Laryngeal Exposure During Suspension Microlaryngoscopy.

Difficult laryngeal exposure during suspension microlaryngoscopic surgeries is a common situation encountered by the phonosurgeons nowadays. It leads to unnecessary trauma, incomplete surgery and even abortion of the procedure. Although various methods have been described to counter the situation, they might not be adequate in some cases with very anteriorly placed larynx. This study is intended to determine the utility of angled rigid endoscope along with malleable endoscopic instruments to improve surgical access in cases with inadequate glottic exposure during suspension microlaryngoscopy. In this cross sectional study conducted at Lokmanya Tilak Municipal Medical College and General Hospital in Mumbai, 50 patients of voice disorders who underwent Suspension Microlaryngoscopy from July 2014 to December 2017 were included. Out of these patients, 5 patients (10%) presented with difficult laryngeal exposure that were operated using readily available angled rigid endoscope along with malleable endoscopic instruments, without requirement of any specially designed instruments. There was improvement in laryngeal exposure in all the cases following utilisation of angled endoscopes. The surgeries were carried out under video monitor guidance with complete excision of the vocal cord lesions. Our study concluded that the cases in which the laryngeal exposure cannot be improved even by various external procedures, can be enhanced by application of angled rigid endoscopes and the vocal cord lesions can be excised completely by using malleable endoscopic instruments.

From Genotype to Phenotype: Through Chromatin.

Advances in sequencing technologies have enabled the exploration of the genetic basis for several clinical disorders by allowing identification of causal mutations in rare genetic diseases. Sequencing technology has also facilitated genome-wide association studies to gather single nucleotide polymorphisms in common diseases including cancer and diabetes. Sequencing has therefore become common in the clinic for both prognostics and diagnostics. The success in follow-up steps, i.e., mapping mutations to causal genes and therapeutic targets to further the development of novel therapies, has nevertheless been very limited. This is because most mutations associated with diseases lie in inter-genic regions including the so-called regulatory genome. Additionally, no genetic causes are apparent for many diseases including neurodegenerative disorders. A complementary approach is therefore gaining interest, namely to focus on epigenetic control of the disease to generate more complete functional genomic maps. To this end, several recent studies have generated large-scale epigenetic datasets in a disease context to form a link between genotype and phenotype. We focus DNA methylation and important histone marks, where recent advances have been made thanks to technology improvements, cost effectiveness, and large meta-scale epigenome consortia efforts. We summarize recent studies unravelling the mechanistic understanding of epigenetic processes in disease development and progression. Moreover, we show how methodology advancements enable causal relationships to be established, and we pinpoint the most important issues to be addressed by future research.

Computed tomographic features of abdominal tuberculosis: unmask the impersonator!

PURPOSE: Abdominal tuberculosis (ATB) mimics various infectious, inflammatory, and neoplastic conditions and hence requires a high index of suspicion for accurate diagnosis, especially in low prevalence areas. It is difficult to consistently establish a histopathological diagnosis of ATB which underlines the importance of supportive evidences for institution of prompt empirical therapy to prevent associated morbidity and mortality. METHODS: We retrospectively evaluated clinical and imaging features of 105 ATB cases and classified their CT findings based on peritoneal, lymph node, bowel, and solid organ involvement. Concomitant pulmonary and extra-pulmonary involvement was assessed. RESULTS: Abdominal pain (78.1%) followed by fever (42.9%) were the commonest presenting symptoms. Peritoneal TB (77.14%) most commonly presented with a mix of ascites (49.38%), peritoneal (28.40%), and omental involvement (27.16%). Lymphadenopathy (57.1%) most commonly presented as necrotic nodes (81.67%) at mesenteric, peripancreatic, periportal, and upper paraaortic regions. Commonest site of bowel involvement (cumulative of 62.85%) was ileocecal region, with the commonest pattern of involvement being circumferential bowel wall thickening without bowel stratification with mild luminal narrowing. Hepatic (13.33%) and splenic (16.2%) involvement predominantly presented as multiple microabscesses. Adrenal and pancreatic involvement was noted in 4.7% and 1.9% of patients, respectively. 38.1% patients showed concomitant pulmonary and extra-pulmonary TB. CONCLUSION: ATB has varied radiological features; however, peritoneal involvement in the form of mild ascites, smooth peritoneal thickening, smudgy omentum, multi-focal bowel involvement, necrotic nodes, and multiple visceral microabscesses point towards a diagnosis of ATB in appropriate clinical setting.