A clinical study on reconstruction of traumatic auricular defects

The auricle or external ear is an important aesthetic subunit of the face. The intricate anatomy due to multiple convolutions along with the thin integument poses a challenge to the reconstructive surgeon. The prominent position of the ear on either side of the face and over a bony prominence makes it more prone for injury. The objective of the study is to describe various traumatic auricular defects and their subsequent reconstructive methods. A retrospective analysis of 15 patients with traumatic auricular defects was carried out over a period of 2 years between the time period of January 2022 and December 2023. Various reconstructive methods such as Primary closure, use of chondral grafts and chondrocutaneous flaps, local flaps were employed depending on the size of the defect and according to the reconstructive ladder. Out of 15 patients, 12 were male and 3 were female, with traumatic ear defects secondary to road traffic accidents (12) and human bite (3). The site of the defect was upper 1/3d (8), upper+middle 1/3rd (3), lower+middle third (2), middle third (1) and lower 1/3rd (1) of the auricle. They were managed by debridement and primary closure in 5 cases, post auricular flap in 5 cases, preauricular flap in 2 cases, peninsular conchal island flap+postauricular flap in 1 case, and bilobed flap in 1 case. All the flaps settled well. 4 patients needed secondary procedures in the form of flap division and contour corrections. This study employed a variety of reconstruction methods of the auricle as per the reconstructive ladder. Some of the patients required secondary procedures. All patients in this study had a satisfactory end aesthetic outcome with no major complications.

Distally based peroneus brevis muscle flap for the use of reconstruction of lower third defects of leg and ankle

Peroneus brevis is a muscle in the lateral compartment of the leg which is expendable with minimal functional deficit. The objective of this study was to find out its use in the coverage of the defects of the lower third of leg and ankle. A retrospective analysis of the use of pedicled peroneus brevis muscle flaps used for coverage of defects of the lower third defects of leg and ankle between May 2022 and 2023 was carried out among 10 patients with said defects. The flaps were distally based for defects the lower third of leg and ankle. Split skin graft coverage was done in all cases. The distally based peroneus brevis muscle flap was used in a series of 10 patients with defects over the lateral malleolus (40%), anterior lower 1/3rd of tibia (40%) and tendoachilles (20%). Flap survival was 100% in all cases with 3 cases having 20% split skin graft loss. Donor site healed well in 100% of cases and no long term muscle function deficit was observed in all cases. This flap has a unique vascular pattern and falls into the type-4 muscle flap category under the Mathes and Nahai Classification. The flap is simple to raise and safe for the reconstruction of small-to moderate-sized skin defects of the distal third of the tibia and all parts of the ankle except the medial malleolus, which is too far from the pedicle of the distally based flap.

Maxillary Schwannoma – A Rare Case Report

Background: Schwannoma or neurilemmoma are a type of nerve sheath tumors. Most of the literature, reports of schwan- noma in the head and neck involve tongue. Intraosseous schwannomas account to about less than 1% with affliction to the mandible over maxilla. Very few cases of maxillary schwannomas have been reported till date. Case presentation: We present one such rare case of schwannoma involving the maxilla extending till the nasal cavity in a 35 years old male. Wide excision of the lesion with hemi-maxillectomy of the right side was done using modified Weber–Fergusson approach (Dieffenbach’s extension). The patient’s postoperative recovery was uneventful without recurrence when followed up till 2 years. Conclusion: Though schwannoma of the Head and neck region are rare, they should be considered as a differential diagnosis of unilateral slow growing mass in the head and neck region, particularly in an adult.

Study of Pulmonary Function and Chest Radiographic Abnormalities in Patients with Rheumatoid Arthritis

Background: Interstitial lung disease (ILD) is one of the important contributors for morbidity and mortality in rheumatoid arthritis (RA) patients. There is paucity of reliable published data on burden of lung disease in RA patients from Andhra Pradesh, India. Materials and methods: This was an observational study in which 88 patients were evaluated. History and clinical features, including disease-severity score, imaging, and pulmonary function tests were recorded. The data were subjected to statistical analysis. Results: The mean age was 49.4 � 10.3 years. Females outnumbered males. Disease duration was less than 2 years in 60.2% of subjects. Respiratory complaints were noted in 12 patients. Seropositivity was noted in 59% of patients. Based on Disease Activity Score 28, high disease activity was seen in 70.5%, moderate activity in 25%, remission in 3.4%, and low activity in 1.1%. Chest radiography showed abnormalities in 4.5%. Pulmonary function tests revealed abnormalities in 23.9% of patients. High disease activity, duration of disease, and seropositivity were not significantly associated with respiratory abnormalities in our study. Conclusion: Patients with RA should be evaluated for pulmonary involvement during their routine follow-up, which can be helpful in early detection and intervention of ILD and therefore reducing morbidity and mortality.

Causes of delayed presentation of pediatric cataract: A questionnaire-based prospective study at a tertiary eye care center in central rural India

Purpose: To find out the sociodemographic, sociocultural, and socioeconomic factors leading to delay in pediatric cataract surgery and its impact on final visual outcome. Methods: A prospective interview-based analytical cohort study was conducted on 156 children aged 0� years with either unilateral or bilateral congenital/developmental cataracts. Caregivers were interviewed using a pretested validated questionnaire. Time intervals between recognition by a caregiver to consultation were denoted as Delay-1 and between consultations to surgical intervention as Delay-2. Spearman's rank correlation was used to determine the presence of correlation between causes of delay and visual outcome. Results: The mean age of presentation was 7.78 � 4.34 years. Mothers were the first informant of the problem (n = 110, 70.5%). Out of 156 children, only 8 (5.1%) children presented to the hospital within 1 month by caregivers and 26 (16.7%) children underwent surgery within 2 months of advice. About 22 (14.1%) children had total cumulative delay of 1�months, 11 (7%) had delay of 6� months, and 115 (73.71%) had delay of >12 months. The most common cause identified for Delay-1 was unawareness in 41 cases (26.28%), however, for Delay-2 major factor responsible was cost (n = 38, 24.35%). The median preoperative visual acuity was 1.31 logMAR and median postoperative visual acuity at 4 weeks was 0.61 logMAR. (P < 0.001) Less age at surgery, upper socioeconomic status, less time delay, and better preoperative vision were positively correlated to better visual outcomes. Conclusion: Delay in presentation for childhood cataract surgery remains a significant problem in central rural India. Delay in surgery is multifactorial which includes unawareness, cost, misdiagnosis, self-treatment, distance from the hospital, lack of family support, and poor socioeconomic status.

Randomized placebo controlled study of diclofenac as premedication for endoscopic retrograde cholangiopancreatography

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure which is commonly performed at various centres. It causes considerable amount of pain and discomfort to patients, and various centres have their own protocols regarding its management. Authors aim to study the efficacy of intravenous diclofenac as a premedication to reduce the pain and discomfort during and after ERCP.Methods: This was a randomized placebo-controlled trial evaluating 40 patients. The pain and degree of discomfort was investigated using a 4- point ordinal scale questionnaire.Results: The use of intravenous diclofenac as premedication for ERCP significantly reduces pain and discomfort during and after the procedure.Conclusions: Intravenous diclofenac should be used as a premedication for ERCP procedure as it significantly reduces the pain and discomfort during and after the procedure.

Audit of 1000 consecutive cases of sutureless cataract surgery in children above two years of age

Purpose: To study the safety of sutureless cataract surgery and risk factors for wound leak of clear corneal incision in children affected with congenital or developmental cataract. Methods: It is a retrospective, noncomparative interventional case study involving children in the age group of 2 to 16 years, who underwent cataract surgery with intraocular lens implantation with the minimum follow up of 1 month. Results: Out of 1000 eyes studied, lens matter aspiration with intraocular lens implantation with or without primary posterior capsulorhexis and anterior vitrectomy was done in 609 and 391 eyes, respectively. Incisions of 943 eyes did not require sutures while sutures were applied for wound leak in 57 eyes on the table and in 5 eyes on postoperative day 1. Risk of wound leak for suture application was found to be greater in patients; having age less than 5 years (P < 0.0001), surgeries performed by junior surgeons (P < 0.0003), wound problems (P < 0.0001), intraocular lens (IOL) related factors (P < 0.0001), use of iris hooks (P < 0.0001), and anterior capsulorhexis extension (P < 0.0001). On the first postoperative day, anterior chamber reaction (P < 0.0001) and fibrinous membrane (P = 0.0007) were significantly more in the sutured group. Incidence of postoperative complications was 0.98 per sutured eyes (59 complications in 60 eyes). One patient developed endophthalmitis after suture removal. Conclusion: Sutureless clear corneal incision in pediatric patients undergoing cataract surgery can achieve stable wound. However, after hydro closure, every wound should be checked for water tightness and the leaky wound should be sutured.

Newer indices for predicting macular hole closure in idiopathic macular holes: A retrospective, comparative study

Purpose: To study the utility and predictive ability of newer macular hole (MH) indices for closure following surgery. Methods: In this retrospective study, pre- and post-operative optical coherence tomography images of 49 eyes with idiopathic full-thickness MH were reviewed and analysed. Various quantitative parameters of MH like maximum outer diameter (OD), minimum diameter between edges, height, nasal and temporal arm lengths, macular hole angle were noted. Indices including hole form factor, Macular Hole Index, (MHI), Diameter Hole Index (DHI) and Tractional Hole Index (THI) were calculated. Newer area indices like macular hole area index (MAI), cystoid space area index (MCSAI) and tissue area index (MTAI) were calculated using Image J (Ver. 1.51). Receiver operating characteristic (ROC) curves and cut-off values were derived for indices predicting type 1 or type 2 closure. Stepwise regression analysis and binary logistic regression analysis were carried out to predict the chances of hole closure. Results: ROC curve analysis showed indices like MHI, THI and MCSAI were capable of successfully predicting type 1 closure while OD, DHI and MAI predicted type 2 closure. On stepwise regression analysis, MAI was identified as the most important index in predicting the type of hole closure. Using the binary logistic regression analysis, the predictive ability of the model to identify success or failure following MH surgery was 89.7% and 80% respectively. Conclusion: MAI measurement could be used as a single important index in predicting hole closure in idiopathic MH. Further research is required to study this area index in detail.

Clinical applications of the retinal functional imager: A brief review

The advances in treating blinding conditions often depends on the development of new techniques that allows early detection, treatment, and follow-up of the disease. Functional changes often precede structural changes in many retinal disorders. Therefore, detecting these changes helps in early diagnosis and management, with the intention of preventing permanent morbidity. The Retinal Functional Imager (RFI) is a non-invasive imaging system that allows us to assess the various functional parameters of the retina. The RFI quantitatively measures the retinal blood-flow velocity, oxygen saturation, metabolic demand and generates a non-invasive capillary perfusion map that provides details similar to a fluorescein angiography. All of these parameters correlate with the health of the retina, and are known to get deranged in retinal disease. This article is a brief review of published literature on the clinical utility of the RFI.

Pattern of steroid misuse in vernal keratoconjunctivitis resulting in steroid induced glaucoma and visual disability in Indian rural population: An important public health problem in pediatric age group

Purpose: To know the pattern of presentations and management outcome of steroid induced glaucoma in vernal keratoconjunctivitis (VKC). Methods: Children of VKC using steroid with two of the following criteria were enrolled: Intraocular pressure (IOP) >21 mm Hg, glaucomatous optic disc and visual field defects. Misused topical steroids were classified in 4 groups; A- Highly potent drugs (dexamethasone, betamethasone), B- Moderate (prednisolone), C- Weak (loteprednol, fluorometholone), D- Unknown drugs. Active/conservative interventions were done to control IOP. Corrected distance visual acuity (CDVA), IOP, anterior segment and fundus examinations were noted. One-way ANOVA test and post hoc Tukey HSD test were used to compare the groups. Results: Out of 1423 VKC patients, 240 were using topical steroid without prescriptions. 92 eyes of 47 patients had steroid induced glaucoma. Hence prevalence of this complication was 3.30% in this study population. Mean age was 14.1 ± 3.8 years. Mean IOP was 38 ± 12 mm of Hg and mean vertical cup disc ratio was 0.67 ± 0.25. IOP was controlled by withdrawal of steroids (9 eyes), with antiglaucoma medications (27), trabeculectomy (57) and glaucoma drainage device (1). Mean CDVA at presentation was better in group C (0.23 log MAR). Mean IOP was highest in group A (43.1 mm Hg) followed by group D (40.5 mm Hg). At presentation 17 were blind (CDVA <3/60). Post treatment marginal improvement in CDVA was found (P = 0.46). However, statistically significantly improvement was noticed in IOP (P < 0.00001). Conclusion: Injudicious use of steroids leads to vision threatening complications like ocular hypertension and glaucoma in children of VKC. Weak steroids like loteprednol or fluorometholone should be used instead of higher potency drugs. Vision and IOP should be monitored fortnightly in children using topical steroids to detect steroid responders at the earliest.

Downregulation of Notch4 - a prognostic marker in distinguishing oral verrucous carcinoma from oral squamous cell carcinoma / Regulação descendente de Notch4 - um marcador prognóstico na distinção entre carcinoma verrucoso oral e carcinoma de células escamosas oral

Abstract Introduction: Oral verrucous carcinoma is a special form of well-differentiated squamous cell carcinoma which possesses specific clinical, morphologic and cytokinetic features that differ from other types of oral cancers and hence diagnosis requires immense experience in histopathology. Hence it is certainly important to distinguish such a lesion from other oral tumors as treatment strategies vary widely between them. Objective: In search of a critical diagnostic marker in distinguishing oral verrucous carcinoma from oral squamous cell carcinoma, Notch4 receptor, one of the key regulatory molecules of the Notch signaling family has been aberrantly activated in the progression of several types of tumors. However its function in oral verrucous carcinoma remains unexplored. Thus the present study aims in determining the differential expression pattern of Notch4 in oral verrucous carcinoma and oral squamous cell carcinoma. Methods: Ten patients reported positive for oral cancer (5 patients with oral verrucous carcinoma and 5 patients with oral squamous cell carcinoma). Five normal tissue samples were also obtained and evaluated for clinicopathological parameters and immunohistochemistry, western blotting and real time polymerase chain reaction for Notch4 expression. Results: Our results reveal that the expression of Notch4 was considerably high in oral squamous cell carcinoma lesions compared to normal tissue, whereas in oral verrucous carcinoma, irrespective of the clinicopathological features, complete regulação descendente of Notch4 was observed. Conclusions: These preliminary findings strongly support the fact that Notch4 is downregulated in oral verrucous carcinoma and could be considered as a suitable prognostic marker in distinguishing oral verrucous carcinoma from oral squamous cell carcinoma. This distinguishing marker can help in improving therapeutic options in patients diagnosed with oral verrucous carcinoma.

Resumo Introdução: O carcinoma verrucoso de cavidade oral é uma forma especial de carcinoma de células escamosas bem diferenciada que tem características clínicas, morfológicas e citocinéticas específicas que diferem de outros tipos de cânceres orais. Por essa razão, o diagnóstico requer grande experiência em histopatologia. Portanto, é certamente importante distingui-lo de outros tumores orais, pois as respectivas estratégias de tratamento variam muito. Objetivo: Em busca de um marcador de diagnóstico crítico na distinção entre o carcinoma verrucoso e o carcinoma de células escamosas de cavidade oral, o receptor Notch4, uma das principais moléculas reguladoras da família de sinalizadores Notch, foi ativado de maneira anormal na progressão de vários tipos de tumores. No entanto, sua função no carcinoma verrucoso permanece inexplorada. Assim, o presente estudo tem como objetivo determinar o padrão de expressão diferencial de Notch4 no carcinoma verrucoso e de células escamosas de cavidade oral. Método: Dez pacientes tiveram resultado positivo para câncer oral (cinco pacientes com carcinoma verrucoso e cinco pacientes com carcinoma de células escamosas) e cinco amostras normais foram também obtidas. Além da avaliação dos parâmetros clínico-patológicos, foram feitos análise imuno-histoquímica, Western Blot e reação de polimerase em cadeia em tempo real para a expressão de Notch4. Resultados: Nossos resultados revelam que a expressão de Notch4 foi consideravelmente alta em carcinomas de células escamosas em comparação com os tecidos normais, enquanto que no carcinoma verrucoso, independentemente das características clínico-patológicas, observou-se regulação descendente completa de Notch4. Conclusão: Esses achados preliminares apoiam fortemente o fato de que Notch4 estava regulado para baixo no carcinoma verrucoso oral e poderia ser considerado um marcador prognóstico adequado para distinguir entre carcinoma verrucoso e carcinoma de células escamosas de cavidade oral. Esse marcador distintivo pode ajudar a melhorar as opções terapêuticas em pacientes com diagnóstico de carcinoma verrucoso oral.

Mucoepidermoid carcinoma of hard palate

Salivary gland tumors are clinically diverse group of neoplasms, of which pleomorphic adenoma and mucoepidermoid carcinoma (MEC) are most common benign and malignant tumors, respectively. Besides the major salivary glands, these tumors can affect the minor salivary gland tissues in the posterior part of the hard palate. Minor salivary gland tumor accounts for about 15% of all the salivary gland neoplasm, of which MEC accounts to about 35.9%. MEC appears as asymptomatic swellings and shows a variety of biological behaviors and variable natural history. This article reports a case of MEC involving the posterior part of the hard palate. The lesion was treated by wide surgical excision with a regular follow-up and no recurrence was noted.

Co-circulation of four dengue serotypes at South Eastern Andhra Pradesh, India: A prospective study

Background: Dengue is one of the most important mosquito-borne viral diseases in the world. The emergence and spread of four dengue viruses (DENVs) (serotypes) represent a global pandemic. The four distinct serotypes are, namely, DENV-1, DENV-2, DENV-3 and DENV-4. Very few dengue serotyping studies have been reported from Andhra Pradesh. In this context, the present study focuses on the circulating serotypes of dengue in South-Eastern Andhra Pradesh. Methodology: Study was done at Sri Venkateswara Institute of Medical Sciences, a teaching hospital in Tirupati, Andhra Pradesh. Acute phase dengue serum samples were collected and tested for NS1 antigen and anti-human IgM antibodies by enzyme-linked immunosorbent assay (ELISA). NS1-positive samples were further serotyped by reverse transcriptase real-time polymerase chain reaction (rRT-PCR). Results: A total of 398 serum samples were received from clinically suspected dengue fever cases. Of these, 150 (37.7%) samples were positive for NS1 and/or IgM ELISA. The 96 NS1 antigen-positive samples were further processed for serotyping, of which 36 were negative by rRT-PCR. DENV-2 (41%) was the predominant serotype, followed by DENV-4 (37%), DENV-3 (12%) and DENV-1 (10%) in descending order. Conclusion: This study reports the all four dengue serotypes' co-circulation. This is the first report from South Eastern Andhra Pradesh. Amongst four, DENV-2 was predominant followed by DENV-4. The information of predominant serotypes can guide in forecasting dengue outbreaks and improving control measures of vectors thus may be helpful in the prevention of outbreaks.

Increasing incidence of adenocarcinoma lung in India: Following the global trend.

BACKGROUND: Lung cancer is one of the most common malignant neoplasms worldwide and accounts for more deaths than any other cancer. The clinicopathological profile of lung cancer has shown marked regional and geographical variation. AIMS: We aimed to compare the demographic and pathological profile of lung cancer patients from North India with other Indian and International series. SETTING AND DESIGN: A retrospective study over a period of 5 years from January 2008 to May 2013 was conducted in the Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi. PATIENTS AND METHODS: A total of 397 newly diagnosed patients with lung cancer from January 2008 to May 2013 were included in the study. The clinical, demographic, and pathological features were reviewed and compared with other major National and International reports. Data were entered and analyzed using SPSS software (SPSS Inc. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc. RESULTS: A total of 397 patients (86% men, mean age 57.8 years) were studied. The ratio of men to women was 7.4. Majority of patients (78.3%) were current/previous smokers. Small cell carcinoma was diagnosed in 14.6% (58) of patients while 85.4% (339) had nonsmall cell lung carcinoma (NSCLC). Within NSCLC, the most common histology types were squamous cell carcinoma (30%), followed closely by adenocarcinoma (ADC) (28.3%) and large cell carcinoma (1.7%). Majority (87%) of the patient were staged III and IV. About 30.1% patients received anti-tubercular treatment during the current episode before a diagnosis of lung cancer was made. CONCLUSION: The clinicopathological profile of lung cancer has undergone noticeable changes over the last four decades, especially in the increase in ADC incidence and their frequent presence in smokers. Lung cancer is often mistreated as tuberculosis in the Indian subcontinent and hence continues to be diagnosed late.