Metagenome Analysis of Cholesteatoma-associated Bacteria: A Pilot Study.

Introduction: Cholesteatoma usually harbors a poly-microbial infection. As the diversity of bacterial pathogens in the Indian COM is unknown, we set out to identify the bacteria associated with cholesteatoma disease in different patients of North India using targeted metagenomic analysis of the 16 S rRNA gene. Methods: We recruited 15 patients of cholesteatomatous chronic otitis media (COM), who underwent surgical disease clearance. We divided these patients into four groups based on the four clinic-radiological stages categorized as per the EAONO/JOS joint consensus statement classification. Representative samples were extracted during the surgery and sent for bacterial culture and sensitivity and 16 S rRNA gene metagenomic analysis. Results: While 12 (80%) of the patients belonged to clinical Stage I/II; one patient had an extracranial complication (stage III) and two patients had an intracranial complication (stage IV). Our detailed bacterial metagenomics analyses showed that while phylum Proteobacteria was most abundant (reads up to ∼ 95%) in specimens from nine patients, phylum Firmicutes was most abundant (up to ∼ 80%) in specimens from four patients. Gamma (γ) Proteobacteria and Epsilon (ε) Proteobacteria were the most abundant class amongst Proteobacteria. Class Tissierellia stood out as the most abundant Firmicutes (40-60%), followed by Clostridia (20%) and Bacilli (10%). There was negligible difference in the bacterial profiles across all four clinical stages. Conclusion: Cholesteatoma is primarily associated with Proteobacteria and Firmicutes phyla, even in complicated disease. Further studies with a larger sample size are required to validate our findings. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-024-04678-9.

Factors Impacting Outcome and Prognosis of Invasive Fungal Sinusitis: How Vital is Iron Metabolism?

Iron is an important micronutrient involved in cell biology through vital reactions. We examined the correlations between iron metabolism parameters and the course of invasive fungal sinusitis. Patients with invasive fungal sinusitis were enrolled. Serum iron and ferritin levels, total iron-binding capacity, and transferrin saturation were measured at the initiation of treatment. Patients were followed for 6 months, and the clinical course was categorised as improvement or worsening/death. A total of 35 patients were enrolled. The average ferritin levels in mucormycosis patients was 944.9 ng/ml, versus 110.7 ng/ml for aspergillosis patients. Iron levels were significantly lower in mucormycosis than in aspergillosis (29.14 µg/dl vs. 68.55 µg/dl). Total iron-binding capacity was significantly different between the two groups (16.76 µg/dl vs. 330.36 µg/dl). After 6 months, improvement, worsening, and death were noted for 18, 8, and 9 patients, respectively. Higher iron levels and lower ferritin levels were linked with improvement. Total iron-binding capacity was significantly higher in improved patients (2314 vs. 151). Iron metabolism parameters play significant roles in the preemptive judgment of the course of fungal sinusitis. Based on these findings, studies on drugs affecting iron metabolism should be conducted.

Pre-vascular Facial Nodes: Sentinel Station for Metastasis in Gingivobuccal Complex Cancers.

BACKGROUND: Pre-vascular facial nodes (PV-FNs; perifacial lymph nodes) are supra-mandibular lymph nodes above the inferior border of the mandible. These are not part of routine neck dissection done for OCSCC. These lymph nodes can be sentinel station for metastatic lymph nodes from gingivobuccal complex cancers and are missed during routine neck dissection. It is imperative to include this sentinel station in routine neck dissection to prevent nodal recurrences. MATERIALS AND METHODS: One hundred thirty-seven patients with GBCC (T1-T4) were prospectively recruited between May 2020 and June 2022 with the intent to evaluate the incidence of PV-FN metastases and clinicopathological factors predicting them. RESULTS: PV-FN metastases were seen in 26 patients (18.9%; 26/137). The occult metastasis rate was 8.7% (12/137). On multivariate analysis, pathological T4 stage (pT4), LVE positivity, and intermediate-high BGS were statistically significant predictors of PV-FN metastases in our study. CONCLUSIONS: Incidence of PV-FN metastasis is high (18.9%) in GBCC, which can be potentially the first sentinel station in the lymphatic drainage pattern for this sub-site. Meticulous clearance of this nodal basin is of paramount importance during neck dissection to prevent nodal recurrences. LEVEL OF EVIDENCE: Level 2 (CEBM-Level of Evidence-2.1) Laryngoscope, 2024.

Perimarginal quadrangle dissection: Pushing the boundaries of neck dissection in gingivo-buccal complex cancer.

OBJECTIVES: Perimarginal nodes (PMN) lie in close relationship with marginal mandibular nerve (MMN), in the lymphatic drainage pathway of gingivo-buccal cancers (GBC), above the lower border of mandible and remain unaddressed in conventional neck dissection. We have aimed to define the boundaries of perimarginal node dissection, explore incidence of PMN metastasis and its correlation with histopathological characteristics. MATERIALS AND METHODS: A prospective study was conducted on 112 consecutive patients of GB carcinoma. PMN dissection was performed in an anatomically defined quadrangle. Prospective clinical characteristics included subsite, tumor and nodal stage, location of primary and clinical skin involvement. Histopathological characteristics analyzed included grade, size, pathological tumor, nodal stage, skin and/or bone involvement, depth of invasion, Brandwein Gensler histological risk score and lympho-vascular emboli. MMN function was graded at 3 and 6 months post-operatively. RESULTS: The PMN were identified histologically in 75.89 % patients. 15.2 % patients harboured metastasis in PMN. 16.7 % patients had clinically occult metastasis with 11.7 % having isolated PMN metastasis. None of the pre-operative clinical factors was found to be significant in predicting incidence of metastasis. Higher nodal burden (p = 0.01) and pathological skin involvement (p = 0.03) were found statistically significant on multivariable analysis. At 6 months follow-up, none of the patients had any MMN functional deformity at rest. CONCLUSION: There is a high incidence of occult PMN metastasis from gingivo-buccal complex cancer. High nodal stage and pathological skin involvement are independent predictors for PMN metastasis. PMN dissection must be performed in all cases of GB cancer.

Multimodality management of locoregionally extensive Marjolin ulcer: a case report and review of the literature.

BACKGROUND: Marjolin ulcer (MU) is an aggressive cutaneous malignancy that commonly occurs in those with a chronic wound such as post-burn scar. CASE REPORT: A 20-year-old male who sustained a flame burn over the scalp at 3 months of age developed a nonhealing ulcer over the burn scar 20 years later, which was treated with adequate surgical margins with adjuvant mold brachytherapy. Two months after completion of that treatment, he developed parotid nodal metastasis with positron emission tomography (PET)-positive bilateral cervical, supraclavicular, right suboccipital, and mesenteric lymph nodes that were treated with concurrent chemoradiation. One month later, the patient developed an ulcerative lesion involving the left parotid region with PET showing infiltration of the parotid gland, but with resolution of other previous sites of uptake. The patient was treated surgically with radical parotidectomy with elective neck dissection and reconstruction with locoregional flap. At 6-month follow-up, the patient developed extensive locoregional recurrence and distant metastasis and was started on oral metronomic therapy. The patient was alive with stable disease at 3-month follow-up after initiation of palliative chemotherapy. CONCLUSION: Despite timely multimodality therapy, MU may present with a hostile clinical course with a short disease-free interval and early recurrence.

Novel Therapeutic Strategies of Non-Invasive Brain Stimulation and Nanomedicine in Pediatric Cerebral Palsy Patients.

Infantile central palsy (CP) is caused due to damage to the immature developing brain usually before birth, leading to altered topography and biochemical milieu. CP is a life-limiting disorder, which causes changes in sensory, motor, cognitive, and behavioral functioning. Understanding its pathophysiology is complex, and current therapeutic modalities, oral medication, surgical treatment, physical therapy, and rehabilitation provide minimal relief. As the brain is plastic, it has an inherent capacity to adapt to altered activity; thus, non-invasive brain stimulation (NIBS) strategies, like repetitive transcranial magnetic stimulation, which can modulate the neuronal activity and its function, may lead to recovery in CP patients. Further, in recent years, nanomedicine has shown a promising approach in pre-clinical studies for the treatment of central nervous system disorder because it can cross the blood-brain barrier, improve penetration, and provide sustained release of the drug. The review focuses on the principles and mechanisms of various NIBS techniques used in CP. We have also contemplated the effect of rehabilitation and nanomedicine in CP children, which will definitely lead to advancing our diagnostic as well as therapeutic abilities, in a vulnerable group of little ones.

Low-molecular-weight heparin salvage in pedicled flap reconstruction in head and neck: a prospective cohort study.

OBJECTIVE: To determine if systemic administration of low-molecular-weight heparin impacts venous compromise in loco-regional flap reconstruction for head and neck subsites. METHODS: This prospective study was conducted on patients who had developed features of venous compromise of the flap. The case group received low-molecular-weight heparin (dalteparin). RESULTS: Of the 73 patients who developed venous congestion, low-molecular-weight heparin was administered in 47 patients. In the low-molecular-weight heparin subset, 23 patients had either reversal or non-progression of venous compromise (48.9 per cent). Of the patients who had no response to low-molecular-weight heparin rescue, complete necrosis was seen in 4 and partial flap necrosis was observed in 19. The corresponding numbers in the control group were 13 and 12, respectively (odds ratio 23.9, p = 0.002). Additionally, the low-molecular-weight heparin arm had a lower incidence of partial or complete flap necrosis (p = 0.002). CONCLUSION: Low-molecular-weight heparin salvage, when instituted early, is likely to result in a significant reduction in flap-related morbidity.

Metagenomic insights into fungal community composition of the nasopharyngeal region of COVID-19 associated mucormycosis patients from India.

Coronavirus disease 2019 (COVID-19) associated mucormycosis (CAM) was reported predominantly from India during the second wave of COVID-19  and has a high mortality rate. The present study aims to understand the fungal community composition of the nasopharyngeal region of CAM-infected individuals and compare it with severe COVID-19 patients and healthy controls. The fungal community composition was decoded by analyzing the sequence homology of the internal transcribed spacer-2-(ITS-2) region of metagenomic DNA extracted from the upper respiratory samples. The alpha-diversity indices were found to be significantly altered in CAM patients (p < 0.05). Interestingly, a higher abundance of Candida africana, Candida haemuloni, Starmerella floris, and Starmerella lactiscondensi was observed exclusively in CAM patients. The interindividual changes in mycobiome composition were well supported by beta-diversity analysis (p < 0.05). The current study provides insights into the dysbiosis of the nasal mycobiome during CAM infection. In conclusion, our study shows that severe COVID-19 and CAM are associated with alteration in mycobiome as compared to healthy controls. However, the sequential alteration in the fungal flora which ultimately leads to the development of CAM needs to be addressed by future studies.

Utility of an in-house real-time PCR in whole blood samples as a minimally invasive method for early and accurate diagnosis of invasive mould infections.

INTRODUCTION: Invasive mould infections (IMIs) are a leading cause of death in patients with compromised immune systems. Proven invasive mould infection requires detection of a fungus by histopathological analysis of a biopsied specimen, sterile culture, or fungal DNA amplification by PCR in tissue. However, the clinical performance of a PCR assay on blood samples taken from patients suspected of invasive mould disease has not been fully evaluated, particularly for the differential diagnosis of invasive aspergillosis (IA) and invasive Mucormycosis (IM). OBJECTIVES: To assess the diagnostic utility of our previously validated in-house real-time PCR in blood samples for diagnosis of invasive aspergillosis and mucormycosis in patients with suspected invasive mould infection. METHODS: All patients with suspected invasive mould infection were prospectively enrolled from May 2021 to July 2021. Conventional fungal diagnosis was performed using tissue and respiratory samples. In-house PCR was performed on blood samples and its diagnostic performance evaluated. RESULTS: A total of 158 cases of suspected invasive mould infection were enrolled in the study. The sensitivity and specificity of in-house PCR performed on blood samples was found to be 92.5% and 81.4% respectively for diagnosis of probable IA, and 65% and 84.62% respectively for diagnosis of proven and probable IM. It was also able to detect 3 out of 5 cases of possible IM where no other microbiological evidence of IM was obtained. CONCLUSIONS: This assay could be helpful in minimally invasive diagnosis of IMIs for patients in whom invasive sampling is not feasible, especially as a preliminary or screening test. It can help in early diagnosis, anticipating conventional laboratory confirmation by days or weeks. Possible correlation between fungal load and mortality can help in initiating aggressive treatment for patients with high initial fungal load.

Quality of life and swallowing outcomes following major glossectomy: A prospective single-center experience.

BACKGROUND: There exists a lacuna in the structured reporting of swallowing dysfunction and quality of life (QoL) outcome following major glossectomy. METHODS: Prospective cohort study to assess the swallowing dysfunction and QoL following STG (subtotal glossectomy) or NTG (near total glossectomy) over a 6-month period using FEES and PAS scale, MDADI, and FACT-HN. RESULTS: Twenty-four patients were available for analysis. The pre- and post-adjuvant evaluation revealed a statistically significant improvement in the composite MDADI and FACT-HN scores. Subscale analysis of FACT-HN scores revealed maximum deficit in the head and neck cancer-specific score domain followed by functional domain and social well-being domain, with serial improvement noted in the post-adjuvant setting. CONCLUSION: This study showed serial improvement in terms of swallowing dysfunction although social and functional well-being domains related to QoL continued to reveal major deficits. Better outcomes were seen with preservation of bilateral base of tongue and mandible.

Evaluation of kit-based loop-mediated isothermal amplification (TB-LAMP) assay in the diagnosis of tubercular lymphadenitis.

Background: The rapid and accurate diagnosis of tubercular lymphadenitis remains a challenging task today. The World Health Organization (WHO) endorsed the LoopAMP MTBC kit (TB-LAMP) as a replacement for sputum smear microscopy in the diagnosis of pulmonary tuberculosis (PTB). However, no prospective diagnostic accuracy study of TB-LAMP for tubercular lymphadenitis in adults has been performed yet. The current study evaluated the diagnostic performance of TB-LAMP in tubercular lymphadenitis (LNTB). Methods: In a prospective observational study conducted at a tertiary care hospital in India, 90 subjects (age >18 years) suspected of LNTB were recruited consecutively and followed up for 6 months between January 2019 and December 2020. Samples were processed for microscopy, culture, GeneXpert, histopathology and TB-LAMP. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TB-LAMP against the composite reference standard (CRS) and culture were determined. Results: TB-LAMP showed a sensitivity of 83.78 % (95 % CI, 73.76-90.47) and a specificity of 81.25 % (95 % CI, 56.99-93.41), respectively, against the CRS. The PPV and NPV were 95.38 % (95 % CI, 87.29-98.42) and 52.00 % (95 % CI, 33.50-69.97), respectively. TB-LAMP showed a sensitivity of 88.89 % (95 % CI, 71.94-96.15) and a specificity of 36.17 % (95 % CI, 23.97-50.46), respectively, against culture. The PPV and NPV were 44.44 % (95 % CI, 32-57.62) and 85 % (95 % CI, 63.96-94.76), respectively. Conclusion: TB-LAMP can be used instead of conventional microscopy for the diagnosis of TB in lymph node specimens at primary healthcare centres. It provides rapid and cost-effective diagnosis of LNTB in resource-limited settings due to good sensitivity and NPV.

Comparison of 68Ga-PSMA-HBED-CC and 18F-FDG PET/CT in the Evaluation of Adenoid Cystic Carcinoma-A Prospective Study.

PURPOSE OF STUDY: 18F-FDG PET/CT plays a major role in diagnosis and staging of head and neck cancer; however, FDG has lower uptake in adenoid cystic carcinoma (AdCC). Prostate-specific membrane antigen (PSMA) expression is found to be associated with endothelial cells or tumor neovasculature in malignant AdCC and salivary duct carcinoma. Thus, present study is aimed to compare the role of 68Ga-PSMA and 18F-FDG PET/CT in patients with primary and/or metastatic AdCC. MATERIALS AND METHODS: Histopathologically proven AdCC patients were intravenously injected with 370 MBq (10 mCi) of 18F-FDG and 111-185 MBq (3-5 mCi) of 68Ga-PSMA. Images were acquired at 60 and 45 minutes postinjection for 18F-FDG and 68Ga-PSMA, respectively, on dedicated PET/CT scanners. Visual and semiquantitative analyses of PSMA expression in regional and metastatic sites were performed by 2 experienced nuclear medicine physicians. RESULTS: Seventeen patients (7 men, 10 women) having mean age of 44 ± 14.19 years were prospectively included in the study. Of 17 patients, FDG PET/CT was performed in only 14 (82%) patients. PSMA and FDG uptakes were seen at the primary site in 16 (94%) and 13 (93%) patients, respectively, whereas 1 patient was postradical tumor excision. Lung lesions (n = 7) and lymph nodes (n = 5) were detected on both FDG and PSMA PET scans. However, cerebellar and meningeal metastasis (n = 1, 6%) and bony lesions (n = 2, 12%) were detected only on PSMA PET/CT but not visualized on FDG PET/CT scan. CONCLUSIONS: PSMA may have theranostic importance in unresectable or metastatic AdCC, besides having a role in staging/restaging.

Normal Serum Levels of Otolin-1 in Patients with Meniere Disease in Remission

Abstract Introduction Degenerative changes in the otolithic organs have been theorized to be caused by the mechanical obstruction to endolymphatic flow, possibly resulting in endolymphatic hydrops (ELH). Otolin-1 is an otoconial matrix protein that crosses the blood labyrinth barrier and has been found in the serum of healthy and diseased patients. Objective To measure the serum levels of Otolin-1 in Meniere disease (MD) patients and compared them with the healthy individuals. Methods This pilot, cross-sectional study was performed at our tertiary care referral center to compare the serum Otolin-1 levels of healthy individuals with those of MD patients. The blood samples were obtained during patients' visit to the vertigo clinic following remission of an acute episode. The data was analyzed using the Stata/SE version 12.0 (StataCorp. College Station, TX, USA). Comparison between the serum Otolin-1 levels in the two groups was performed using the unpaired t-test. A p-value of 0.05 was considered to be statistically significant. Results The participants were divided into two groups, with 31 MD patients, and 30 age and gender-matched members of the control group. The serum levels of Otolin-1 in MD patients (247.6, ± 44.2 pg/ml) were not found to be significantly different from those of the control group (236.2, ± 43.5 pg/ml) (p = 0.31). Conclusion The current study reveals that the serum levels of Otolin-1 are not significantly different between the patients with MD in the interictal phase and the control group's healthy ones.

Perineural Invasion of Superior and Inferior Laryngeal Nerves in Advanced Stage Squamous Cell Carcinoma of the Larynx: A Case Series and Review.

Objective: To evaluate bilateral superior and recurrent laryngeal nerves for tumor spread in patients of advanced-stage laryngeal carcinoma undergoing surgical resection. Methods: A prospective study was conducted including biopsy-proven cases of laryngeal squamous cell carcinoma (SCC) that were planned for total laryngectomy. Patients with metachronous or synchronous SCC were excluded from the study. All patients underwent total laryngectomy, where both superior and recurrent laryngeal nerves were harvested along with the specimen, and the proximal ends of the nerves were marked for reference. Perineural invasion (PNI) was assessed in nerves within the tumor and in bilateral extra-laryngeal nerves. Results: The study included 22 patients with a mean age of 58 years. Intra-tumoral PNI was found in 7 of the 22 cases (32%). The free nerve margins of superior and recurrent laryngeal nerves, which were examined from proximal to distal orientation, showed no tumor infiltration in any of the cases. Conclusion: Perineural invasion of minor nerves constitutes a major pathway of spread. On the contrary, invasion of superior or recurrent laryngeal nerves does not constitute a route for tumor spread. Hence, there is no need to extend the surgical boundary for total laryngectomy to include these major nerves separately.

Normal Serum Levels of Otolin-1 in Patients with Meniere Disease in Remission.

Introduction Degenerative changes in the otolithic organs have been theorized to be caused by the mechanical obstruction to endolymphatic flow, possibly resulting in endolymphatic hydrops (ELH). Otolin-1 is an otoconial matrix protein that crosses the blood labyrinth barrier and has been found in the serum of healthy and diseased patients. Objective To measure the serum levels of Otolin-1 in Meniere disease (MD) patients and compared them with the healthy individuals. Methods This pilot, cross-sectional study was performed at our tertiary care referral center to compare the serum Otolin-1 levels of healthy individuals with those of MD patients. The blood samples were obtained during patients' visit to the vertigo clinic following remission of an acute episode. The data was analyzed using the Stata/SE version 12.0 (StataCorp. College Station, TX, USA). Comparison between the serum Otolin-1 levels in the two groups was performed using the unpaired t -test. A p -value of 0.05 was considered to be statistically significant. Results The participants were divided into two groups, with 31 MD patients, and 30 age and gender-matched members of the control group. The serum levels of Otolin-1 in MD patients (247.6, ± 44.2 pg/ml) were not found to be significantly different from those of the control group (236.2, ± 43.5 pg/ml) ( p = 0.31). Conclusion The current study reveals that the serum levels of Otolin-1 are not significantly different between the patients with MD in the interictal phase and the control group's healthy ones.

Utility of in-house and commercial PCR assay in diagnosis of Covid-19 associated mucormycoss in an emergency setting in a tertiary care center.

Introduction. Invasive mucormycosis (IM) is a potentially fatal infection caused by fungi of the order Mucorales. Histopathology, culture, and radiology are the mainstays of diagnosis, but they are not sufficiently sensitive, resulting in delayed diagnosis and intervention. Recent studies have shown that PCR-based techniques can be a promising way to diagnose IM.Hypothesis/Gap Statement. Early diagnosis of fungal infections using molecular diagnostic techniques can improve patient outcomes, especially in invasive mucormycosis.Aim. The aim of this study was to evaluate the utility of our in-house mould-specific real time PCR assay (qPCR) in comparison with the commercially available real time PCR (MucorGenius PCR), for the early diagnosis of mucormycosis in tissue samples from patients with suspicion of invasive mucormycosis (IM). This in-house assay can detect and distinguish three clinically relevant mould species, e.g. Aspergillus spp., Mucorales and Fusarium spp. in a single reaction with only one pair of primers, without the need for sequencing.Methodology. We enrolled 313 tissue samples from 193 patients with suspected IM in this prospective study. All cases were classified using EORTC/MSGERC guidelines. All samples were tested using traditional methods, in-house qPCR, and MucorGenius PCR.Results. Using direct microscopy as a gold standard, the overall sensitivity and specificity of in-house qPCR for detection of IM was 92.46% and 80% respectively, while that of the MucorGenius PCR was 66.67% and 90% respectively. However, co-infection of IM and IA adversely affected the performance of MucorGenius PCR in detection of IM.The in-house PCR detected Aspergillus spp. in 14 cases and Fusarium spp. in 4 cases which showed clinical and radiological features of fungal sinusitis. The in-house qPCR also performed better in detecting possible cases of IM. This aids early diagnosis and appropriate treatment to improve patient outcomes.Conclusion. Because the in-house PCR is not only sensitive and specific, but also entirely based on SYBR Green for detection of targets, it is less expensive than probe-based assays and can be used on a regular basis for the diagnosis of IM in resource-constrained settings. It can be used to distinguish between mucormycosis and fungal sinusitis caused by Aspergillus and Fusarium in high-risk patients, as well as to accurately detect Mucorales in fungal co-infection cases.

Role of ApneaGraph® in the Surgery for Obstructive Sleep Apnoea.

AIM: To evaluate the utility of ApneaGraph® AG 200 in diagnosing Obstructive Sleep Apnoea (OSA) as compared to Polysomnography, localization of the site of upper airway obstruction, and the success rate of surgery. METHODS: A prospective study was conducted including fifteen patients of OSA undergoing surgical treatment. All patients underwent sequential overnight ApneaGraph (AG) and Polysomnogram (PSG) before and after 3 months following surgery. The preoperative and post-operative Apnoea-Hypopnoea Index (AHI) values were compared between AG and PSG. The success of surgery was defined as mean reduction in AHI by ≥ 50% and post-operative AHI < 20. RESULTS: The mean preoperative AHI using PSG was 53.7 and using AG was 44.9 (r = 0.83, p = 0.0001). All patients underwent AG-directed site-specific surgery. The mean postoperative AHI using PSG was 15.3 and using AG was 13.8 (r = 0.67, p = 0.0062). There was significant improvement in AHI post-surgery (p < 0.05, AG & PSG). The surgical success was achieved in 93.3%. The median follow-up was 14 months. CONCLUSION: ApneaGraph is a reliable alternative to PSG to diagnose OSA with an added advantage to localize the site of obstruction, yielding good surgical outcomes.

Childhood and Adolescent Sleep Awareness in Caregivers and Health Care Providers: A Community- and Hospital-Based Survey.

BACKGROUND: Sleep disorders are common in childhood and adolescence with mental and physical consequences needing appropriate intervention by caregivers and health care providers (HCPs). The objective of the study, conducted at a tertiary teaching hospital and public school in north India, was to develop validated questionnaires to evaluate childhood and adolescent sleep awareness in caregivers and HCPs. METHODS: The study participants (caregivers represented by parents of 2-18 year olds attending a public school and of those attending outpatient services at the study hospital and HCPs represented by medical interns and nursing graduates within 1 year of graduation) were enrolled after appropriate screening. RESULTS: Two separate questionnaires in English for caregivers (also translated in Hindi) and HCPs were applied on 313 caregivers and 175 HCPs (110 medical interns and 65 nursing graduates) and developed and validated with a Cronbach α of 0.73 and 0.74, respectively. The questionnaires covered three domains: sleep hygiene, sleep related health problems, and miscellaneous. Both group of respondents had >50% correct responses in sleep hygiene. The ĸ agreement between knowledge and practice of sleep hygiene in caregivers was 0.2. Poor response (<50% correct responses) was seen in sleep-related health problems in both groups of respondents implying knowledge deficit in various sleep disorders. The HCPs performed poorly on basic theoretical questions in miscellaneous domain. For consultation of sleep problems, most caregivers (48%) chose pediatricians. CONCLUSION: There is a need to strengthen undergraduate medical and nursing curriculum in sleep. Caregivers should be made aware of implications of unhealthy sleep.

Evaluation of high-risk human papillomavirus in sinonasal papillomas and squamous cell carcinomas.

The sinonasal tract is considered a second hotspot for human papillomavirus (HPV)-related tumors in the head and neck, with HPV being identified in up to 62% of squamous cell carcinomas (SCCs) and 38% of papillomas. There is limited data from geographical regions with low prevalence of high-risk (HR)-HPV on the association of HR-HPV in sinonasal neoplasms and on utility of p16 as a surrogate marker. p16 immunohistochemistry, HR-HPV mRNA ISH and quantitative real-time PCR (qPCR) were performed on a retrospective cohort of sinonasal papillomas and SCCs. KRAS mutation analysis was done in oncocytic papillomas. p16 positivity was present in 22/142 cases (15.5%) including eight inverted papillomas, one oncocytic papilloma (OP), and 13 SCC. Among these, mRNA ISH showed HR-HPV in the OP and two SCC, while another SCC was found to harbour HPV18 by qPCR. Two HPV-associated SCCs had foci of OP. mRNA ISH was negative in all p16 negative cases. p16 immunohistochemistry showed 68% concordance with mRNA ISH, and had sensitivity and negative predictive value of 100%; specificity was 67%, and positive predictive value was 14.3%. Association with HR-HPV in sinonasal papillomas and SCC is rare, and may be seen in cases demonstrating oncocytic morphology. p16 immunohistochemistry has low specificity and positive predictive value in low-prevalence populations; thus, reflex direct HR-HPV testing should be performed in p16 immunopositive cases. This two-step approach is viable in resource-limited settings, as the proportion of p16 positive cases is small.