An initial experience of computed tomography-guided trans superior vena caval biopsy: a novel approach for precarious mediastinal lesions.

Purpose: As interventional radiologists, we encounter precarious deep-seated mediastinal lesions in our day-to-day practice. The conventional technique of percutaneous transthoracic biopsy of these lesions carries significant intrinsic complications. Endovascular approaches for such lesions under fluoroscopic guidance have been described in previous literature but with significant technical constraints. In this article, we would like to describe the novel approach of computed tomography (CT)-guided trans superior vena caval biopsy, which we have performed in 3 consecutive precarious mediastinal lesions. Material and methods: We placed a vascular sheath under ultrasound and fluoroscopic guidance considering the intended angle of needle puncture and length to reach the target lesion from the puncture site. With the sheath in situ, the trans superior vena caval biopsy was performed under CT guidance, and multiple cores of target tissue were safely and successfully obtained. Results: We have carefully and successfully employed this novel technique of CT-guided trans superior vena caval approach for 3 tricky deep-seated mediastinal lesions with very low risk of complications. Conclusions: Through this article, we would like to enhance the importance of thought-provoking new techniques in tackling complex challenging referrals.

Evaluation of anti-LipL32 carbon nanotube immunofluorescence probe (carbo-lip) and comparison with MAT, IgM ELISA, IgM spot test and culture for early detection of leptospirosis at local hospital.

Leptospirosis is an emerging public health problem affecting people mainly from tropical and subtropical regions. Therefore, there is a need for rapid and sensitive tests for proper and prompt treatment. Recently we have demonstrated Carbo-Lip probe, which was fabricated through immuno recognition method with fluorescent dye functionalized LipL32 monoclonal antibodies, secondary antibody and Leptospira for rapid and accurate diagnosis. In an effort to validate Carbo-Lip, we collected clinical samples from a cohort of 104, consisting of 26 positive, 40 negative and 38 unconfirmed cases of Leptospirosis. Subsequently, the test was also compared and validated with the gold standard method microscopic agglutination test (MAT), IgM ELISA, IgM spot test, and culture. Carbo-Lip exhibited a sensitivity of 75% with specificity of 92.3% for Leptospirosis in comparison with MAT. The fabricated Carbo-Lip sensor could be used as a potential diagnostic tool for early detection of Leptospirosis in patients from endemic areas.

Halving Time of BCR-ABL1 in Chronic Myeloid Leukemia: Is It Better Than Day-90 Value-A Multicenter Study From South India.

BACKGROUND: The 90-day BCR-ABL1 (breakpoint cluster region-Abelson 1) level has been one of the accepted milestones for predicting the molecular response in patients with chronic myeloid leukemia (CML). The rate of decline in BCR-ABL1 has been considered a better predictor of the response but has not been uniformly accepted. A paucity of evidence is available to predict the accuracy of the rate of decline in the Indian context. Therefore, we tested the accuracy of the rate of decline of BCR-ABL1 in predicting the molecular response compared with the single 90-day values in a retrospective cohort study of selected cancer centers in south India. METHODS AND MATERIALS: Patients with chronic-phase CML diagnosed from January 2013 to December 2018, the serial BCR-ABL1 levels were estimated at 0, 45, and 90 days, 6 months, and 1 year. Data on patient demographics, risk stratification assessed using the Sokal and EUTOS (European Treatment and Outcome Study) scores were extracted using a mobile-based data capture tool from the medical records of the enrolled patients. The halving time, determined by log reduction, was compared with the 90-day BCR-ABL1 values using the receiver operating characteristic curve for the major and complete molecular response at 6 months and 1 year as standards. Accuracy was determined from the area under the curve. The cutoff for the halving time was chosen to balance the sensitivity and specificity. RESULTS: The rate of decline had more predictive accuracy compared with the 90-day BCR-ABL1 values (area under the curve for rate of decline, 0.83; 90-day, 0.80). A halving time of < 20 days identified 95% of the patients who had achieved major molecular response at 12 months compared with 80% using the single 90-day BCR-ABL1 response. CONCLUSIONS: The halving time of BCR-ABL1 appears promising as a predictor of the outcomes for patients with CML.

Does Interim PET Scan After 2 Cycles of ABVD Predict Outcome in Hodgkin Lymphoma? Real-World Evidence.

PURPOSE: Escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) improves overall survival (OS) in patients with Hodgkin lymphoma (HL) relative to ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) therapy. However, the associated higher cost and toxicity discourage clinicians from prescribing it. Identifying high-risk patients and administering escalated BEACOPP remains an effective strategy. We assessed the significance of interim positron emission tomography (iPET) scan after 2 cycles (iPET2) in identifying this high-risk subset. PATIENTS AND METHODS: This cohort study used secondary data from 12 tertiary care centers in South India gathered over 10 years (2008-2018). OS, event-free survival (EFS), determinants of EFS, and complete response (CR) in iPET2 were assessed. RESULTS: The study included 409 patients with HL (mean age, 34.5 years; male/female ratio, 1.4:1). The median duration of follow-up was 2.8 years. Of 409 patients, 63% underwent PET-based staging and 37% underwent computerized tomography (CT) staging. Stage IV (28.9%) and bone involvement (9.2%) were seen more often with PET than with CT staging (9.2% and 2%, respectively). Among 171 patients with iPET2 results, 24% did not achieve CR, and no factors were significantly associated. The 5-year EFS and OS rates of the entire cohort were 78% and 97%, respectively. The 5-year EFS and OS rates of patients with CR on iPET2 were 90% and 99%, respectively, whereas these were 65% and 100%, respectively, for patients not achieving CR. On univariable analysis, sex, stage, and iPET2 response significantly predicted inferior EFS. On multivariate analysis, only iPET2 response significantly predicted EFS (P < .000). CONCLUSION: Our study supports the use of PET for staging and iPET2 for response assessment. Nonachievement of CR on iPET2 indicates unfavorable outcome, and such patients may benefit from more intensive treatment.

Comparison of Microbiological Flora in the External Auditory Canal of Normal Ear and an Ear with Acute Otitis Externa.

INTRODUCTION: Acute Otitis Externa (AOE) is also known as swimmer's ear. Investigations initiated during World War II firmly established the role of bacteria in the aetiology of Acute Otitis Externa. AIM: To culture the microbiological flora of the normal ear and compare it with the flora causing AOE and to know the role of normal ear canal flora and anaerobes in the aetiology. MATERIALS AND METHODS: A prospective observational study was conducted on 64 patients clinically diagnosed with unilateral AOE. Ear swabs were taken from both the ears. Microbiological flora was studied considering diseased ear as test ear and the normal ear as the control. Aerobic and anaerobic cultures were done. Severity of the disease was assessed by subjective and objective scores. Effect of topical treatment with ichthammol glycerine pack was assessed after 48 hours and scores were calculated again. Patients with scores < 4 after pack removal were started on systemic antibiotics and were assessed after seven days of antibiotics course. Data was analysed using Paired t-test, Wilcoxon signed ranks test and Chi-square test. A p-value < 0.05 was considered significant. RESULTS: Pseudomonas aeruginosa (33%) was the most common bacteria cultured from the ear followed by Methicillin Resistant Staphylococcus aureus (MRSA) (18%). Patients with anaerobic organism in the test ear had severe symptoms and needed systemic antibiotic therapy. CONCLUSION: Most of the cases may respond to empirical antibiotic therapy. In cases with severe symptoms and the ones refractory to empirical treatment, a culture from the ear canal will not be a tax on the patient. This helps in giving a better understanding about the disease, causative organisms and helps in avoiding the use of inappropriate antibiotics that usually result in developing resistant strains of bacteria.

Total knee arthroplasty in vascular malformation.

In Klippel-Trenaunay syndrome, vascular malformations are not only in skin and superficial soft tissues but also in deep tissues like muscles bones and joints. It is well documemted that these recurrent intraarticular bleeds can cause early arthritis and joint pain. Performing arthroplasty in such patients is difficult and fraught with complications. We describe such a case where navigated total knee arthroplasty was performed with success to avoid the problems of intra medullary alignment used in the presence of intra medullary vascular malformations. We also suggest certain measures when knee arthroplasty is considered in such patients.

Wound healing effect of Vimlapanakarma with Jatyadi tailam in diabetic foot.

INTRODUCTION: Diabetic Foot ulcer is the commonest burning problem in the society. Many histopathological studies show prolonged inflammatory phase in diabetic wounds. In Sushruta Samhita, Vimlapanakarma (gentle massage) quoted, as first line of treatment for Vranashotha (inflammation). CASE REPORT: A 70 yrs old male patient, presented with complaints of ulcer associated with severe pain and reddish skin discoloration over ventral aspect of 3(rd) toe of right foot since 2 months. Vimlapanakarma performed with Jatyadi taila around the wound for about 15-20 minutes daily for 10 days and follow-up done for period of 45 days. DISCUSSION: By Vimlapanakarma with Jatyadi taila there will be raised local temperature, due to which vasoconstriction is relieved and necessary nutrients, oxygen, insulin etc. are carried to the wound site, thereby improving the anoxic condition of wound. CONCLUSION: Vimlapanakarma showed significant role in wound healing of Diabetic Foot ulcer, in a short period of time 10 days with no recurrence seen till 45 days follow-up.

A unique nonsurgical management of internal hemorrhoids by Jimutaka Lepa.

This is the era of fast foods. Irregularity in food timing, improper diet, and mental stress coupled with a sedentary life disturb the digestive system resulting in increased incidence of hemorrhoids. In the present report, we present two cases of intero-external hemorrhoids. Case 1: A 30-year old young male approached with intero-external hemorrhoid at 11 O'clock position as a primary. Case 2: A 41-year-old female visited with second degree intero-external hemorrhoid at 11 O'clock position. Hemorrhoids present in these patients can be considered as Kaphaja Arsa. These cases were diagnosed by per rectal digital and proctoscopic examinations by ayurvedic proctologists. In both cases, application of Jimutaka Lepa was done under local anesthesia administered using lignocaine 2% with adrenaline. This was followed by manual anal dilatation. Jimutaka Lepa was applied to the internal hemorrhoids (Arsa). Changes were observed in the form of edema, ulcer in 3-4 days and sloughing out of the pile mass up to 5-7 days. Subsequently fibrosis of hemorrhoidal masses started after 7 days. Jimutaka Lepa shows a significant effect in obliterating the hemorrhoidal mass within a month of application. The patients were followed-up regularly with proctoscopic examination in each visit and did not reveal any evidence of recurrence of the hemorrhoids.

Primary Amoebic Meningoencephalitis in an Infant due to Naegleria fowleri.

Primary amoebic meningoencephalitis (PAM) caused by free-living amebae Naegleria fowleri is a rare and fatal condition. A fatal case of primary amoebic meningoencephalitis was diagnosed in a 5-month-old infant who presented with the history of decrease breast feeding, fever, vomiting, and abnormal body movements. Trophozoites of Naegleria fowleri were detected in the direct microscopic examination of CSF and infant was put on amphotericin B and ceftazidime. Patient condition deteriorated, and he was discharged against medical advice and subsequently expired. We also reviewed previously reported 8 Indian cases of primary amoebic meningoencephalitis (PAM) and observed that for the last 5 years, none of the patients responded to amphotericin B. Has an era of amphotericin B-resistant Naegleria fowleri been emerged? Management strategy of PAM needs to be reviewed further.

Carcinoma of the oesophagus masquerading as actinomycosis: a case report and a review of literature.

Actinomycosis is a granulomatous lesion caused by actinomyces species, which is an anaerobic non-spore forming gram-positive bacillus. It is a relatively uncommon disease which occurs as opportunistic infection. Most of the reported cases have underlying diseases predisposing them to actinomycosis3. This case report is presented to illustrate the necessity to exclude an underlying disease that may predispose individuals to secondary infection caused by actinomycosis. Two weeks after discharge the patient returned to hospital with symptom of dysphagia. Actinomycosis is not an uncommon disease which occurs throughout the world. Carcinoma of the oesophagus needs to be excluded in a patient with dysphagia and weight loss. Actinomycosis and carcinoma of the oesophagus may coexist in patient with dysphagia. The need for repeated upper gastrointestinal endoscopy and biopsy to confirm or exclude a primary diagnosis of oesophageal actinomycosis has been endorsed by many authors.

Pacific Telepathlogy Service at Fiji School of Medicine.

Pacific Telepathology service has been established at Fiji school of Medicine (FSM) with technical support from University of Basel. The service is designed for remote consultation, continuing medical education (CME) health care research (HCR). To develop Telepathology services for participation with international Telepathology community for improving quality of health care in the Pacific. Telepathology server for "Pacific Pathology Group" has been set up at http://telepath.patho.unibas.ch/, which is dedicated for Telepathology consultations bring together health care professionals in the Pacific to overcome limitations of distance, lack of resources and to improve quality of healthcare services, Accessed by a computer possessing Internet and email connection, members send cases and questions, review and comment on other cases and receive consultation via web or email. Benefits are tremendous in terms of remote consultation, CME, HCR and improving quality of modern health care even at remote islands devoid of health care resources. Internet speed or reliability is not a limiting factor. Virtual institute of pathology has been established in Switzerland with over 400 Pathologists and is providing consultations to many countries including Solomon Islands where there is no pathologist. The institute is functioning efficiently with average reporting turnaround time of 48 hours. Efficiency is the result of organization and communication. Presently this Service has been established at the FSM in Fiji Islands primarily for education & remote consultation with plans to expand to other island countries.

Stomatal control in tomato with ABA-deficient roots: response of grafted plants to soil drying.

The hypothesis that ABA produced by roots in drying soil is responsible for stomatal closure was tested with grafted plants constructed from the ABA-deficient tomato mutants, sitiens and flacca and their near-isogenic wild-type parent. Three types of experiments were conducted. In the first type, reciprocal grafts were made between the wild type and sitiens or flacca. Stomatal conductance accorded with the genotype of the shoot, not the root. Stomates closed in all of the grafted plants in response to soil drying, regardless of the root genotype, i.e. regardless of the ability of the roots to produce ABA. In the second type of experiment, wild-type shoots were grafted onto a split-root system consisting of one wild-type root grafted to one mutant (flacca or sitiens) root. Water was withheld from one root system, while the other was watered well so that the shoots did not experience any decline in water potential or loss of turgor. Stomates closed to a similar extent when water was withheld from the mutant roots or the wild-type roots. In the third type of experiment, grafted plants with wild-type shoots and either wild-type or sitiens roots were established in pots that could be placed inside a pressure chamber, and the pressure increased as the soil dried so that the shoots remained fully turgid throughout. Stomates closed as the soil dried, regardless of whether the roots were wild type or sitiens. These experiments demonstrate that stomatal closure in response to soil drying can occur in the absence of leaf water deficit, and does not require ABA production by roots. A chemical signal from roots leading to a change in apoplastic ABA levels in leaves may be responsible for the stomatal closure.