Treatment algorithm for post sternotomy wound infection - our experience.

INTRODUCTION: Median sternotomy is the most commonly used approach in open cardiac surgery. As in any other surgery, surgical site infections are a known phenomenon, but morbidity depends on the depth of infection. Superficial wound infections can be managed conservatively; however, deep sternal wound infections need an aggressive approach to prevent disastrous consequence like mediastinitis. Hence, this study was conducted with the aim to classify sternotomy wound infection and to develop a treatment algorithm for superficial and deep sternotomy wound infections. MATERIAL AND METHODS: Between January 2016 to August 2021, 25 patients who had sternotomy wound infections were studied. These wound infections were classified as superficial or deep sternal wound infections. RESULTS: Superficial wound infections underwent treatment with diluted vinegar dressings and deep infections underwent treatment with bilateral pectoralis major muscle advancement flaps. Patients were followed up till the wounds healed completely without complications. Patient characteristics, comorbidities, duration of treatment and outcomes of treatment were analyzed. Superficial sternal wound infection patients responded favorably to diluted vinegar dressings and deep sternal wound infection patients to pectoralis major muscle advancement flaps. Average time duration of healing for superficial and deep wound infections was 66.2 days and 18 days respectively. None of the patients had an increased severity of infection or re-dehiscence following treatment and during follow-up. CONCLUSION: Relatively conservative approach using diluted vinegar (1% acetic acid) dressing for superficial sternal wound infections was efficacious, whereas aggressive debridement and bilateral pectoralis major advancement muscle flaps for deep sternal wound infections are necessary for favorable outcomes. However, more studies are needed to ascertain this treatment algorithm.

Restriction Spectrum Imaging-Magnetic Resonance Imaging to Improve Prostate Cancer Imaging in Men on Active Surveillance.

PURPOSE: Restriction spectrum imaging-magnetic resonance imaging is a short duration enhanced diffusion-weighted technique that seeks to standardize sequences and predict upgrading. We test this technology for active surveillance biopsies. Our objective is to investigate the utility of restriction spectrum imaging-magnetic resonance imaging to improve upgrading detection in a prostate cancer active surveillance cohort. MATERIALS AND METHODS: We prospectively enrolled men on active surveillance undergoing repeat biopsy from January 2016 to June 2019. Subjects underwent prostate multiparametric magnetic resonance imaging and restriction spectrum imaging-magnetic resonance imaging reviewed by a urological radiologist for PI-RADS® scored lesions, followed by magnetic resonance imaging-guided prostate biopsy by a urologist. Restriction spectrum imaging-magnetic resonance imaging analysis with proprietary research software (CorTechs Labs, San Diego, California) generated a restricted signal map. We compared the restricted signal map and apparent diffusion coefficient values using T-test, ANOVA, and logistic regression analyses for prediction of upgrading. RESULTS: Of 123 enrolled men we identified 74 restriction spectrum imaging-magnetic resonance imaging regions of interest (targeted lesions) in 110 subjects, with 105 subjects completing biopsy. The restricted signal map was significant per PI-RADS score for true-positive lesion detection (mean difference 28, SD 0.7, p=0.001), and better than apparent diffusion coefficient (mean difference -15, SD 55, p=0.6). Restriction spectrum imaging generated restricted signal map values >50 improved sensitivity, specificity, positive predictive value and negative predictive value (81.0%, 81.8%, 54.2% and 94.2%) over PI-RADS ≥3 (71.4%, 38.9%, 23.7% and 83.7%, respectively) for Gleason upgrading. Overall restriction spectrum imaging is able to improve the AUC of 0.70 (95% CI 0.49-0.92, p=0.03) to 0.90 (95% CI 0.82-0.98, p <0.001). CONCLUSIONS: Restriction spectrum imaging-magnetic resonance imaging enhances the standard PI-RADS system by providing a noninvasive radiological biomarker to predict upgrading in active surveillance.

Pulsed quantum cascade laser based hypertemporal real-time headspace measurements.

Optical cavity enhancement is a highly desirable process to make sensitive direct-absorption spectroscopic measurements of unknown substances, such as explosives, illicit material, or other species of interest. This paper reports advancements in the development of real-time cavity ringdown spectroscopy over a wide-bandwidth, with the aim to make headspace measurements of molecules at trace levels. We report results of two pulsed quantum cascade systems operating between (1200 to 1320)cm(-1) and (1316 to 1613)cm(-1) that measure the headspace of nitromethane, acetonitrile, acetone, and nitroglycerin, where the spectra are obtained in less than four seconds and contain at least 150,000 spectral wavelength datapoints.

Thoracic Epidural Chronic Inflammatory Lesion: A Case Report and Review of Literature.

Chronic inflammatory lesions (CIL) in the body are rare and inflammatory pseudotumor (IPT) is a subtype of CIL. Spine is an uncommon location of CIL, with most cases reported in the thoracic spine. Our objective was to review the current literature on IPT. To the best of our knowledge only about 13 cases are reported till date. A retrospective review of 13 existing cases was done. The etiopathogenesis of CIL is uncertain and total surgical excision remains the mainstay. It's a diagnosis of exclusion after ruling out commonly found lesions, both clinically and radiologically. Only histopathology can confirm the diagnosis. Total surgical resection remains the mainstay of treatment with adjuvant treatment only if there is a residue or a recurrence. CILs are rare lesions in the body with IPT being the commonest. Surgical excision remains the mainstay of treatment and a long-term follow up is warranted.

Prostate MRI for the detection of clinically significant prostate cancer: Update and future directions.

PURPOSE OF REVIEW: In recent decades, there has been an increasing role for magnetic resonance imaging (MRI) in the detection of clinically significant prostate cancer (csPC). The purpose of this review is to provide an update and outline future directions for the role of MRI in the detection of csPC. RECENT FINDINGS: In diagnosing clinically significant prostate cancer pre-biopsy, advances include our understanding of MRI-targeted biopsy, the role of biparametric MRI (non-contrast) and changing indications, for example the role of MRI in screening for prostate cancer. Furthermore, the role of MRI in identifying csPC is maturing, with emphasis on standardization of MRI reporting in active surveillance (PRECISE), clinical staging (EPE grading, MET-RADS-P) and recurrent disease (PI-RR, PI-FAB). Future directions of prostate MRI in detecting csPC include quality improvement, artificial intelligence and radiomics, positron emission tomography (PET)/MRI and MRI-directed therapy. SUMMARY: The utility of MRI in detecting csPC has been demonstrated in many clinical scenarios, initially from simply diagnosing csPC pre-biopsy, now to screening, active surveillance, clinical staging, and detection of recurrent disease. Continued efforts should be undertaken not only to emphasize the reporting of prostate MRI quality, but to standardize reporting according to the appropriate clinical setting.

Current Insights into Molecular Mechanisms and Potential Biomarkers for Treating Radiation-Induced Liver Damage.

Highly conformal delivery of radiation therapy (RT) has revolutionized the treatment landscape for primary and metastatic liver cancers, yet concerns persist regarding radiation-induced liver disease (RILD). Despite advancements, RILD remains a major dose-limiting factor due to the potential damage to normal liver tissues by therapeutic radiation. The toxicity to normal liver tissues is associated with a multitude of physiological and pathological consequences. RILD unfolds as multifaceted processes, intricately linking various responses, such as DNA damage, oxidative stress, inflammation, cellular senescence, fibrosis, and immune reactions, through multiple signaling pathways. The DNA damage caused by ionizing radiation (IR) is a major contributor to the pathogenesis of RILD. Moreover, current treatment options for RILD are limited, with no established biomarker for early detection. RILD diagnosis often occurs at advanced stages, highlighting the critical need for early biomarkers to adjust treatment strategies and prevent liver failure. This review provides an outline of the diverse molecular and cellular mechanisms responsible for the development of RILD and points out all of the available biomarkers for early detection with the aim of helping clinicians decide on advance treatment strategies from a single literature recourse.

Offline estimation of decay time for an optical cavity with a low pass filter cavity model.

This Letter presents offline estimation results for the decay-time constant for an experimental Fabry-Perot optical cavity for cavity ring-down spectroscopy (CRDS). The cavity dynamics are modeled in terms of a low pass filter (LPF) with unity DC gain. This model is used by an extended Kalman filter (EKF) along with the recorded light intensity at the output of the cavity in order to estimate the decay-time constant. The estimation results using the LPF cavity model are compared to those obtained using the quadrature model for the cavity presented in previous work by Kallapur et al. The estimation process derived using the LPF model comprises two states as opposed to three states in the quadrature model. When considering the EKF, this means propagating two states and a (2×2) covariance matrix using the LPF model, as opposed to propagating three states and a (3×3) covariance matrix using the quadrature model. This gives the former model a computational advantage over the latter and leads to faster execution times for the corresponding EKF. It is shown in this Letter that the LPF model for the cavity with two filter states is computationally more efficient, converges faster, and is hence a more suitable method than the three-state quadrature model presented in previous work for real-time estimation of the decay-time constant for the cavity.

Secondary syphilis presenting with "crown of Venus" alopecia.

Since the era of antibiotics, the frequency of secondary syphilis manifestations has declined. During the last decade, there has been a resurgence of syphilis cases. We describe a case of a 28-year-old man with various secondary syphilis symptoms including alopecia with the well-described characteristic "crown of Venus" pattern not commonly seen during this decade, as well as mucosal plaques, pustules, and palmoplantar macular rash. This case suggests that syphilis should be included in the differential diagnosis of hair loss for a correct screening, diagnosis, and early treatment.

Prospective comparison of restriction spectrum imaging and non-invasive biomarkers to predict upgrading on active surveillance prostate biopsy.

BACKGROUND: Protocol-based active surveillance (AS) biopsies have led to poor compliance. To move to risk-based protocols, more accurate imaging biomarkers are needed to predict upgrading on AS prostate biopsy. We compared restriction spectrum imaging (RSI-MRI) generated signal maps as a biomarker to other available non-invasive biomarkers to predict upgrading or reclassification on an AS biopsy. METHODS: We prospectively enrolled men on prostate cancer AS undergoing repeat biopsy from January 2016 to June 2019 to obtain an MRI and biomarkers to predict upgrading. Subjects underwent a prostate multiparametric MRI and a short duration, diffusion-weighted enhanced MRI called RSI to generate a restricted signal map along with evaluation of 30 biomarkers (14 clinico-epidemiologic features, 9 molecular biomarkers, and 7 radiologic-associated features). Our primary outcome was upgrading or reclassification on subsequent AS prostate biopsy. Statistical analysis included operating characteristic improvement using AUROC and AUPRC. RESULTS: The individual biomarker with the highest area under the receiver operator characteristic curve (AUC) was RSI-MRI (AUC = 0.84; 95% CI: 0.71-0.96). The best non-imaging biomarker was prostate volume-corrected Prostate Health Index density (PHI, AUC = 0.68; 95% CI: 0.53-0.82). Non-imaging biomarkers had a negligible effect on predicting upgrading at the next biopsy but did improve predictions of overall time to progression in AS. CONCLUSIONS: RSI-MRI, PIRADS, and PHI could improve the predictive ability to detect upgrading in AS. The strongest predictor of clinically significant prostate cancer on AS biopsy was RSI-MRI signal output.

Nonlinear estimation of ring-down time for a Fabry-Perot optical cavity.

This paper discusses the application of a discrete-time extended Kalman filter (EKF) to the problem of estimating the decay time constant for a Fabry-Perot optical cavity for cavity ring-down spectroscopy (CRDS). The data for the estimation process is obtained from a CRDS experimental setup in terms of the light intensity at the output of the cavity. The cavity is held in lock with the input laser frequency by controlling the distance between the mirrors within the cavity by means of a proportional-integral (PI) controller. The cavity is purged with nitrogen and placed under vacuum before chopping the incident light at 25 KHz and recording the light intensity at its output. In spite of beginning the EKF estimation process with uncertainties in the initial value for the decay time constant, its estimates converge well within a small neighborhood of the expected value for the decay time constant of the cavity within a few ring-down cycles. Also, the EKF estimation results for the decay time constant are compared to those obtained using the Levenberg-Marquardt estimation scheme.

Microsurgery of Giant Intracranial Aneurysm: A Single Institution Outcome Study.

BACKGROUND: Giant intracranial aneurysms (GIAs) are treacherous lesions and in spite of the many advances, endovascular therapy (EVT) of GIAs is challenging. OBJECTIVE: A retrospective analysis of our results with microsurgery of GIAs is presented to examine the role of microsurgery in the current trend of EVT. MATERIALS AND METHODS: Between 1996 and 2019, 134 patients with 147 GIAs had microsurgery by the senior author in a single institute. The medical and imaging records for all the patients were reviewed. The patient outcome was determined by modified Rankin scale (mRS); ≤3 was considered as a good outcome. Statistical analysis was done using the SPSS program and odds ratios and their 95% confidence intervals were computed; a probability value of < 0.05 was considered significant. RESULTS: There were 123 aneurysms (83.7%) in the anterior circulation and 24 aneurysms (16.3%) in the posterior circulation. Overall 103 out of 134 (76.8%) patients had a good outcome postoperatively. Good preoperative mRS score (≤3) had an overall good prognosis in the postoperative period and was statistically significant (P = 0.000, odds ratio: 0.036, 95% CI: 0.008-0.171). Presence of subarachnoid hemorrhage (SAH) was also statistically significant for good outcome (P = 0.04, odds ratio: 2.898, 95% CI: 1.051-7.991), but age was not a significant prognostic factor. Mortality within 30 days of treatment was 4.47%. CONCLUSION: GIAs need treatment because of their dismal natural history. Results of microsurgical treatment by a single surgeon of the large current series compare well with the results of EVT and justifies pursuing microsurgery for GIAs.

Profile of patients presenting with seizures as emergencies and immediate noncompliance to antiepileptic medications.

INTRODUCTION: Seizure is a common manifestation of the many neurological conditions faced by primary care physicians. This study aims to determine the prevalence, etiology, and predictors of immediate noncompliance of adult patients presenting with seizures to the department of emergency (ED). MATERIALS AND METHODS: We conducted this study in the ED of CMC, Vellore from November 2015 to February 2016. Retrospective chart review was used to gather specific data regarding these consecutive cases. RESULTS: During the study period, 477 patients presented with seizures. The prevalence of nontrauma seizures in the ED was 2.3% [Figure 1]. The mean age was 41.4 ± 17.25 years. There was a male predominance (63.1%). About 11.7% had active seizures at presentation to the ED and less than a quarter (21.8%) were determined to have status epilepticus. Nearly 41% had new-onset seizures with common etiologies being idiopathic generalized epilepsy (22.6%), metabolic causes (17.9%), acute febrile illnesses (14.42%), and space-occupying lesions (12.3%). Among those with a history of seizures (58.9%), 87.9% were advised regular medications but 58.5% of them were immediately noncompliant. Phenytoin (58.6%), sodium valproate (20.5%), and levetiracetam (18%) were the most commonly used antiepileptics with 23% on multidrug therapy. About 60% were discharged stable from the ED. Univariate analysis showed chronic alcohol consumption (OR: 2.78; 95% CI: 1, 7.7) and female sex (OR: 1.45; 95% CI: 1-2.5) to be predictors of immediate noncompliance to antiepileptics. CONCLUSION: Common etiologies of new-onset seizures in the ED are idiopathic generalized epilepsy, metabolic causes, and acute febrile illnesses. More than half the patients with a known seizure disorder are immediately noncompliant to the advised medications. Knowledge among primary healthcare physicians about the importance of emphasizing compliance will greatly reduce the burden of seizures.

Aberrant expression and localization of decorin in human oral dysplasia and squamous cell carcinoma.

The small leucine-rich proteoglycan decorin has been associated with negative regulation of cell growth. It has a prominent role in transforming growth factor (TGF)-beta and epidermal growth factor receptor activation pathways that contributes to its role in cellular proliferation, angiogenesis, and immunomodulation. Our studies are directed toward analysis of decorin gene expression, identified through DNA microarray studies, in oral premalignant and malignant tissues as well as representative cell lines of an oral cancer progression model. We have used long oligonucleotide microarray analysis, immunohistochemistry, confocal microscopy, reverse transcription-PCR, sequencing, and Western immunoblot techniques to characterize decorin expression in oral premalignant archival tissues and an oral cancer progression cellular model. We have further analyzed the deduced amino acid sequence derived from full-length cDNA that do not show any deletion or mutations of the decorin expressed in oral premalignant and malignant cell lines. In our studies, we show aberrant expression of decorin in dysplastic oral epithelial cells. Both promoters P1 and P2 drive the aberrant expression resulting in exon 1a as well as exon 1b carrying transcripts. Intracellular accumulation and nuclear localization of aberrantly expressed decorin were observed in dysplastic oral tissues and in the respective cell lines. Decorin expressed in oral cancer may have lost its ability to inhibit TGF-beta signaling and activate epidermal growth factor receptor signaling pathways because of such aberrant nuclear localization, resulting in a major dysfunction of otherwise a natural extracellular antagonist of TGF-beta and a putative tumor suppressor protein. The aberrant nuclear localization of a leucine-rich repeat protein might result in additional protein-protein interactions and resulting changes in gene expression. Further studies to characterize such interacting proteins and localization-dependent effects of aberrant decorin expressed in oral cancer progression are warranted.

Identification of genes and molecular pathways involved in the progression of premalignant oral epithelia.

An early interventional effort in oral premalignancy requires novel molecular targets and diagnostic biomarkers to delay or reverse incidences of malignant progression. Microarray-based transcriptional profiling in disease states provides global insight into the causal biomolecular processes and novel pathways involved. In this study, we investigated transcript profiles in precancerous oral lesions to identify nearly 1,700 genes as significantly overexpressed or underexpressed and a primarily affected metabolic pathway that may be responsible for irreversible transition to progressive stages of oral cancer. For the first time, we show a convergence of several genes and pathways known for their oncogenic capabilities, in progression of premalignant oral epithelial tissues. This study consequently provides a molecular basis for persistent proinflammatory conditions in oral premalignant tissues. We found that lipocalin-type prostaglandin D(2) synthase (PTGDS), a key enzyme in the arachidonic acid metabolism pathway, as repressed in premalignant stages. We show the protective role of these enzyme-derived metabolites in inhibiting cell proliferation using an in vitro oral cancer progression model. We have also confirmed the overexpression of two invasion-related biomarkers, psoriasin (PSOR1) and versican (CSPG2), in oral premalignant and malignant archival tissues. Our results clearly indicate that pharmacologic intervention with anti-inflammatory prostaglandin D(2)-like analogues may help prevent or delay oral epithelial carcinogenesis because of metabolic restoration of a negative feedback regulatory loop through its several cognate receptors or target molecules. Further studies directed toward a multitude of possible protective mechanisms of this lipocalin-type enzyme or its products in oral cancer progression are warranted.

Petrous apex cephalocele presenting with cerebrospinal fluid rhinorrhea in an adult.

Petrous apex cephalocele (PAC) is a rare condition with very few case reports in the literature. We report a 26-year-old man with cerebrospinal fluid rhinorrhea that was misdiagnosed elsewhere and operated unsuccessfully via the endonasal route. CT cisternography revealed a 3mm right PAC for which he underwent a right subtemporal extradural approach and successful repair. We present what is to our knowledge the first case report in the literature of an adult presenting with cerebrospinal fluid leak and discuss the diagnostic dilemmas in the diagnosis of PAC, difficulties in management and review the available literature.

Deregulated cyclooxygenase-2 expression in oral premalignant tissues.

Establishment of an early and reliable biomarker for oral carcinogenesis whose expression can be monitored through noninvasive techniques will enable early diagnosis of cancer. Cyclooxygenases (COXs) have been implicated previously in several human malignancies, and the therapeutic benefit of specific COX-2 inhibitors has been elucidated. The expression of COX-2 and subsequent markers of malignant progression was studied in archival human specimens representing premalignant and malignant stages of oral cancer. We find that changes in COX-2 gene expression precede changes in expression of biomarkers related to apoptosis and angiogenesis in oral premalignant tissues as a veritable phenotype. We also report for the first time COX-2 mRNA variants in dysplastic samples and in a human papillomavirus-transformed cell line HOK-16B, indicating a possible stabilization of COX-2 message by human papillomavirus infection as an early event in oral cancer. Expression of other markers of tumor progression related to apoptosis and angiogenesis pathway genes shows relatively low level of changes in oral premalignant tissue. However, a determinant shift toward decrease in antitumor immunity was observed by cytokine gene expression profile changes.

Expression of biomarkers modulating prostate cancer angiogenesis: differential expression of annexin II in prostate carcinomas from India and USA.

BACKGROUND: Prostate cancer (PCa) incidences vary with genetic, geographical and ethnic dietary background of patients while angiogenesis is modulated through exquisite interplay of tumor-stromal interactions of biological macromolecules. We hypothesized that comprehensive analysis of four biomarkers modulating angiogenesis in PCa progression in two diverse populations might explain the variance in the incidence rates. RESULTS: Immunohistochemical analysis of 42 PCa biopsies reveals that though Anx-II expression is lost in both the Indian and American population with Gleason scores (GS) ranging between 6 and 10, up to 25 % of cells in the entire high grade (GS > 8) PD PCa samples from US show intense focal membrane staining for Anx-II unlike similarly graded specimens from India. Consistent with this observation, the prostate cancer cell lines PC-3, DU-145 and MDA PCa 2A, but not LNCaP-R, LNCAP-UR or MDA PCa 2B cell lines, express Anx-II. Transcriptional reactivation of Anx-II gene with Aza-dC could not entirely account for loss of Anx-II protein in primary PCa. Cyclooxygenase-2 (COX-2) was moderately expressed in most of high grade PIN and some MD PCa and surrounding stroma. COX-2 was not expressed in PD PCa (GS approximately 7-10), while adjacent smooth muscles cells stained weakly positive. Decorin expression was observed only in high grade PIN but not in any of the prostate cancers, atrophy or BPH while stromal areas of BPH stained intensively for DCN and decreased with advancing stages of PCa. Versican expression was weak in most of the MD PCa, moderate in all of BPH, moderately focal in PD PC, weak and focal in PIN, atrophy and adjacent stroma. CONCLUSIONS: Expression of pro- and anti-angiogenic modulators changes with stage of PCa but correlates with angiogenic status. Focal membrane staining of Anx-II reappears in high grade PCa specimens only from US indicating differential expression of Anx-II. COX-2 stained stronger in American specimens compared to Indian specimens. The sequential expression of DCN and VCN in progressive stages was similar in specimens from India and USA indicating no population-based differences. The mechanistic and regulatory role of Anx-II in PCa progression warrants further investigation.

Dorsally exophytic cervicomedullary glioblastoma.

Spinal glioblastoma multiforme is a rare entity comprising 1.5% of all spinal cord tumors. We report a 57-year-old man presenting with a 1.5 month history of left sided radiculopathy, lower cranial nerve weakness and difficulty in walking. MRI of the brain and spine showed an exophytic intramedullary lesion extending from the cervicomedullary junction to the lower margin of C4. To our knowledge, we report the first patient with dorsally exophytic cervicomedullary and cervical intramedullary glioblastoma multiforme.

Spontaneous cervical intradural disc herniation.

Cervical intradural disc herniation (IDH) is a rare condition with very few case reports in the literature. We report a 64-year-old man who presented with sudden onset neck pain and rapidly progressing weakness in the left upper and lower limb. There was no history of trauma. MRI of the cervical spine showed a C6-C7 disc prolapse, for which he underwent a C6-C7 discectomy and fusion with bone graft through an anterior cervical approach. To our knowledge, all patients with a cervical IDH reported in the literature have a traumatic etiology. To the best of our knowledge, we report the first patient with a spontaneous cervical IDH.