A Cross-Sectional Observational Study to Assess the Efficacy of Triglyceride to High-Density Lipoprotein Ratio as a Marker of Insulin Resistance in Subjects of Central Rural India.

INTRODUCTION: The rising prevalence of insulin resistance (IR), obesity, and its complications in India is due to lifestyle changes, eating patterns, stress, and genetic factors. Markers for IR are often expensive, invasive, or impractical for use in economically disadvantaged or remote areas. To address this, we evaluated the efficacy of the triglyceride to high-density lipoprotein (TG/HDL) ratio as a simple, reliable, accessible, and affordable surrogate marker of IR in comparison to the homeostatic model assessment for insulin resistance (HOMA-IR). METHODS: This cross-sectional observational study was performed at a tertiary care center in central India and included 815 subjects aged 18 to 60 years after excluding those with systemic diseases, drugs affecting weight, or pregnant or lactating women. Descriptive and inferential statistical analysis was done to represent the study findings. RESULTS: Males and obese subjects were more insulin resistant than females and non-obese subjects, respectively. The TG/HDL had a sensitivity of 91.81%, a specificity of 92.88%, a positive predictive value of 94.46%, and a negative predictive value of 89.56%, with a diagnostic accuracy of 92.27% when compared to HOMA-IR. CONCLUSION: We concluded that TG/HDL serves as a simple, affordable, and accurate marker of IR in a diverse population of central India. There is a definite scope to use the same for large-scale screening, epidemiological research, and routine clinical practice.

Real-World Utilization of Radiation Therapy in Multiple Myeloma: An Analysis of the Connect MM Registry.

PURPOSE: Radiation therapy (RT) is an important treatment modality for patients with multiple myeloma (MM). Although patients are living longer with MM, they are more likely to have comorbidities related to treatment, such as bone pain; however, RT can provide symptom relief. To date, the characterization of patients who have received RT in the real-world setting has been limited. METHODS AND MATERIALS: The Connect® MM Registry is a large, US multicenter, prospective observational cohort study of adult patients with newly diagnosed MM from mostly community sites. RT utilization and outcomes were analyzed quarterly throughout treatment. Factors associated with RT use were identified via multivariable analysis. RESULTS: A total of 3011 patients were enrolled in the Connect MM Registry with 903 patients (30%) having received RT at any time. There was a significant difference (P < .05) in overall RT use among patients with an Eastern Cooperative Oncology Group performance status of 0 to 1 versus ≥2, International Staging System disease stage I/II versus III, a history of plasmacytoma or a novel agent in their first regimen, and any number of bone lesions or severe osteoporosis/fracture. RT use was associated with having bone lesions or severe osteoporosis (vs not having bone lesions). Additionally, RT use was associated with ethnicity (Hispanic vs not) and Connect MM Registry cohort (cohort 1 [enrolled 2009-2011] vs 2 [enrolled 2012-2016]). In the 6 months before death, increased RT use was associated with increasing number of treatment lines (P < .0001) and high- versus standard-risk disease (per International Myeloma Working Group criteria; P = .0028). CONCLUSIONS: Real-world results from the Connect MM Registry show RT is frequently used and is associated with clinical factors, including performance status and disease stage. Earlier in MM diagnosis, RT may be used as an adjunct to palliate symptoms or delay systemic therapy. Toward the end of life, RT is more frequently used for palliation when treatment options are often limited.

MASC Gets UNMASKED: Visiting a Rare Tumor with Emphasis on Cytomorphological Features.

Background: Secretory carcinoma (SC) is a newly described entity which has been often misdiagnosed earlier as acinic cell carcinoma on cytology. Diagnosing SC was initially based upon identifying the ETV6:NTRK3 fusion gene with the help of fluorescence in situ hybridization (FISH). Lately, with more knowledge of the reliable histomorphology, cytology, and immunohistochemistry features, definitive diagnosis can be confidently made without the help of FISH in almost every case. Materials and Methods: Six histologically confirmed cases of SC were studied. The cytology slides of all the six cases were retrieved and reviewed to identify the characteristic features which could have helped in raising the possibility of SC on fine needle aspiration cytology itself. Cell blocks were also studied, wherever available. Results: Patients were all male with average age of 35.2 years. The six cases in the current study demonstrated at least focal cytoplasmic vacuolization of varying sizes, papillae formations, and bland nuclear features on fine needle aspirate smears. It was also seen that S-100 and mammaglobin immunohistochemistry (IHC) are very helpful in confirming the diagnosis. Conclusions: The results of the current study highlight the cytomorphological features which may help in clinching the diagnosis SC on cytology itself. They also highlight certain cytological features which help to rule out the other differential diagnoses.

Transcending the challenge of evolving resistance mechanisms in Pseudomonas aeruginosa through ß-lactam-enhancer-mechanism-based cefepime/zidebactam.

Multi-drug resistant (MDR) Pseudomonas aeruginosa harbor a complex array of ß-lactamases and non-enzymatic resistance mechanisms. In this study, the activity of a ß-lactam/ß-lactam-enhancer, cefepime/zidebactam, and novel ß-lactam/ß-lactamase inhibitor combinations was determined against an MDR phenotype-enriched, challenge panel of P. aeruginosa (n = 108). Isolates were multi-clonal as they belonged to at least 29 distinct sequence types (STs) and harbored metallo-ß-lactamases, serine ß-lactamases, penicillin binding protein (PBP) mutations, and other non-enzymatic resistance mechanisms. Ceftazidime/avibactam, ceftolozane/tazobactam, imipenem/relebactam, and cefepime/taniborbactam demonstrated MIC90s of >128 mg/L, while cefepime/zidebactam MIC90 was 16 mg/L. In a neutropenic-murine lung infection model, a cefepime/zidebactam human epithelial-lining fluid-simulated regimen achieved or exceeded a translational end point of 1-log10 kill for the isolates with elevated cefepime/zidebactam MICs (16-32 mg/L), harboring VIM-2 or KPC-2 and alterations in PBP2 and PBP3. In the same model, to assess the impact of zidebactam on the pharmacodynamic (PD) requirement of cefepime, dose-fractionation studies were undertaken employing cefepime-susceptible P. aeruginosa isolates. Administered alone, cefepime required 47%-68% fT >MIC for stasis to ~1 log10 kill effect, while cefepime in the presence of zidebactam required just 8%-16% for >2 log10 kill effect, thus, providing the pharmacokinetic/PD basis for in vivo efficacy of cefepime/zidebactam against isolates with MICs up to 32 mg/L. Unlike ß-lactam/ß-lactamase inhibitors, ß-lactam enhancer mechanism-based cefepime/zidebactam shows a potential to transcend the challenge of ever-evolving resistance mechanisms by targeting multiple PBPs and overcoming diverse ß-lactamases including carbapenemases in P. aeruginosa.IMPORTANCECompared to other genera of Gram-negative pathogens, Pseudomonas is adept in acquiring complex non-enzymatic and enzymatic resistance mechanisms thus remaining a challenge to even novel antibiotics including recently developed ß-lactam and ß-lactamase inhibitor combinations. This study shows that the novel ß-lactam enhancer approach enables cefepime/zidebactam to overcome both non-enzymatic and enzymatic resistance mechanisms associated with a challenging panel of P. aeruginosa. This study highlights that the ß-lactam enhancer mechanism is a promising alternative to the conventional ß-lactam/ß-lactamase inhibitor approach in combating ever-evolving MDR P. aeruginosa.

A Comprehensive Review on Chemistry and Biology of Tafamidis in Transthyretin Amyloidosis.

Transthyretin amyloid cardiomyopathy and Transthyretin amyloid peripheral neuropathy are progressive disease conditions caused by Transthyretin amyloidosis (ATTR) fibril infiltration in the tissue. Transthyretin (TTR) protein misfolding and amyloid fibril deposits are pathological biomarkers of ATTR-related disorders. There are various treatment strategies targeting different stages in pathophysiology. One such strategy is TTR tetramer stabilization. Recently, a new TTR tetramer stabilizer, tafamidis, has been introduced that reduces the protein misfolding and amyloidosis and, consequently, disease progression in ATTR cardiomyopathy and peripheral neuropathy. This review will provide a comprehensive overview of the literature on tafamidis discovery, development, synthetic methods, pharmacokinetics, analytical methods and clinical trials. Overall, 7 synthetic methods, 5 analytical methods and 23 clinical trials have been summarized from the literature.

Evaluation of Madras Diabetes Research Foundation-Indian Diabetes Risk Score in detecting undiagnosed diabetes in the Indian population: Results from the Indian Council of Medical Research-INdia DIABetes population-based study (INDIAB-15).

Background & objectives: Screening of individuals for early detection and identification of undiagnosed diabetes can help in reducing the burden of diabetic complications. This study aimed to evaluate the performance of Madras Diabetes Research Foundation (MDRF)-Indian Diabetes Risk Score (IDRS) to screen for undiagnosed type 2 diabetes in a large representative population in India. Methods: Data were acquired from the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study, a large national survey that included both urban and rural populations from 30 states/union territories in India. Stratified multistage design was followed to obtain a sample of 113,043 individuals (94.2% response rate). MDRF-IDRS used four simple parameters, viz. age, waist circumference, family history of diabetes and physical activity to detect undiagnosed diabetes. Receiver operating characteristic (ROC) with area under the curve (AUC) was used to assess the performance of MDRF-IDRS. Results: We identified that 32.4, 52.7 and 14.9 per cent of the general population were under high-, moderate- and low-risk category of diabetes. Among the newly diagnosed individuals with diabetes [diagnosed by oral glucose tolerance test (OGTT)], 60.2, 35.9 and 3.9 per cent were identified under high-, moderate- and low-risk categories of IDRS. The ROC-AUC for the identification of diabetes was 0.697 (95% confidence interval: 0.684-0.709) for urban population and 0.694 (0.684-0.704) for rural, as well as 0.693 (0.682-0.705) for males and 0.707 (0.697-0.718) for females. MDRF-IDRS performed well when the population were sub-categorized by state or by regions. Interpretation & conclusions: Performance of MDRF-IDRS is evaluated across the nation and is found to be suitable for easy and effective screening of diabetes in Asian Indians.

Uncovering the Unusual: A Case of Mixed Connective Tissue Disease With Rare Presentation, Atypical Complications, and Therapeutic Dilemmas.

Mixed connective tissue disease (MCTD) is an overlap syndrome characterized by features of systemic lupus erythematosus, scleroderma, and polymyositis, along with the presence of the U1RNP antibody. A 46-year-old female patient presented with severe anemia, cough, and breathlessness, and was diagnosed with cold agglutinin disease, a type of autoimmune hemolytic anemia (AIHA). Autoimmune workup revealed MCTD by positive antinuclear and U1RNP antibodies. She had bilateral miliary mottling on X-ray and a tree-in-bud appearance on high-resolution computed tomography of the thorax, which were suggestive of pulmonary tuberculosis. Standard therapy with steroids was not advisable. She was subsequently started on anti-tuberculosis treatment (anti-Koch's therapy), followed by steroid therapy and immunosuppressive therapy after three weeks. The patient responded well to treatment, but after two months, she developed cytomegalovirus (CMV) retinitis. Adult-onset CMV disease may occur as a result of primary infection, reinfection, or activation of a latent infection. Although not directly related, it can occur as an atypical association in the setting of immunosuppressive therapy. Morbidity and mortality are significantly increased in this population secondary to infectious potentiation: immunosuppression causes infections, and infections cause AIHA. The management of MCTD and secondary AIHA and immunosuppression poses a therapeutic challenge.

Association of vitamin D with the severity of disease and mortality in COVID-19: Prospective study in central India.

Background: Many factors have been proposed to be associated with the severity of disease and mortality in COVID-19. Vitamin D had recently been reviewed as one of these factors. Aim and Objectives: To evaluate the association between Vitamin D and the disease severity and mortality in COVID-19. Materials and Methods: After approval from Institutional Ethics Committee, this prospective cohort study was carried out in selected tertiary care teaching medical institutes of Central India. Participants were COVID-19 patients of the age group of 18 years and above admitted during the study period. They were categorized into four groups as asymptomatic (Group A), mild (Group B), moderate (Group C), and severe (Group D) based on clinical symptoms, respiratory rate, oxygen saturation, and chest imaging. Serum level of Vitamin 25(OH) D was measured using chemiluminescent immunoassay. The outcome of the disease was classified as recovery and death during hospitalization. The association of sociodemographic and medical characteristics with treatment outcome was studied using an appropriate statistical test. A full logistic regression model was built for the assessment of the relationship between treatment outcomes with Vitamin D level. Further, one receiver operating characteristic curve was developed to examine the prognostic significance of Vitamin D levels in COVID-19 patients. Results: Out of 748 enrolled patients, 44 (5.88%), had severe disease (Group D). A total of 721 cases (96.39%) recovered and were discharged, whereas 27 (3.61%) died during hospitalization. Mean Vitamin D level was found to be significantly different in discharged patients compared to those who were deceased. Increasing age-adjusted odds ratio (AOR) (95% confidence interval [CI]=1.07 [1.02-1.12]), known hypertension AOR (95%CI) = 3.38 (1.13-10.08), and diabetes mellitus AOR (95%CI) =28.5 (6.04-134.13) were found to be significant predictors of death among COVID-19 patients. Increasing Vitamin D level was found to be protective against COVID-19-related death (AOR (95% CI = 0.87 [0.80-0.94]). Conclusion: Vitamin D was significantly associated with the disease severity and mortality in COVID-19.

Résumé Contexte: Il a été proposé que de nombreux facteurs soient associés à la gravité de la maladie et de la mortalité dans le Covid - 19. La vitamine D avait récemment été examinée comme l'un de ces facteurs. Objectif et objectifs: évaluer l'association entre la vitamine D et la gravité de la maladie et la mortalité dans le Covid-19. Matériel et méthodes: Après l'approbation du comité d'éthique institutionnel, cette étude de cohorte prospective a été réalisée dans des instituts médicaux d'enseignement des soins tertiaires de l'Inde centrale. Les participants étaient des patients Covid-19 du groupe d'âge de 18 ans et plus admis au cours de la période d'étude. Ils ont été classés en quatre groupes comme asymptomatiques (groupe A), légers (groupe B), modérés (groupe C) et sévères (groupe D) sur la base des symptômes cliniques, de la fréquence respiratoire, de la saturation en oxygène et de l'imagerie thoracique. Niveau sérique de la vitamine 25 (OH) DWAS mesuré en utilisant l'immunodosage chimioluminescent. L'issue de la maladie a été classée comme récupération et décès pendant l'hospitalisation. L'association des caractéristiques sociodémographiques et médicales avec les résultats du traitement a été étudiée à l'aide d'un test statistique approprié. Un modèle de régression logistique complet a été construit pour l'évaluation de la relation entre les résultats du traitement au niveau de la vitamine D. De plus, une courbe caractéristique de fonctionnement du récepteur a été développée pour examiner la signification pronostique des niveaux de vitamine D chez les patients COVID-19. Résultats: Sur 748 patients inscrits, 44 (5,88%), avaient une maladie grave (groupe D). Un total de 721 cas (96,39%) ont récupéré et ont été libérés, tandis que 27 (3,61%) sont décédés pendant l'hospitalisation. Le niveau moyen de la vitamine D s'est révélé significativement différent chez les patients libérés par rapport à ceux qui ont été décédés. Augmentation du rapport de cotes ajusté à l'âge (AOR) (intervalle de confiance à 95% [IC] = 1,07 [1,02­1,12]), hypertension connue AOR (IC à 95%) = 3,38 (1,13­10,08) et diabète mellite aor (IC 95% ) = 28,5 (6,04­134.13) se sont révélés être des prédicteurs significatifs de la mort chez les patients COVID-19. L'augmentation du niveau de vitamine D s'est avérée protectrice contre la mort liée au Covid - 19 (AOR (IC à 95% = 0,87 [0,80­0,94]). Conclusion: La vitamine D était significativement associée à la gravité de la maladie et à la mortalité dans le Covid - 19. Mots clés: Covid - 19, tempête de cytokines, mortalité, gravité, vitamine D.

Polyploidy on islands - concerted evolution and gene loss amid chromosomal stasis.

BACKGROUND AND AIMS: Polyploidy is an important process that often generates genomic diversity within lineages, but it can also cause changes that result in loss of genomic material. Island lineages, while often polyploid, typically show chromosomal stasis but have not been investigated in detail regarding smaller-scale gene loss. Our aim was to investigate post-polyploidization genome dynamics in a chromosomally stable lineage of Malvaceae endemic to New Zealand. METHODS: We determined chromosome numbers and used fluorescence in situ hybridization to localize 18S and 5S rDNA. Gene sequencing of 18S rDNA, the internal transcribed spacers (ITS) with intervening 5.8S rDNA, and a low-copy nuclear gene, GBSSI-1, was undertaken to determine if gene loss occurred in the New Zealand lineage following polyploidy. KEY RESULTS: The chromosome number for all species investigated was 2n = 42, with the first published report for the monotypic Australian genus Asterotrichion. The five species investigated all had two 5S rDNA signals localized interstitially on the long arm of one of the largest chromosome pairs. All species, except Plagianthus regius, had two 18S rDNA signals localized proximally on the short arm of one of the smallest chromosome pairs. Plagianthus regius had two additional 18S rDNA signals on a separate chromosome, giving a total of four. Sequencing of nuclear ribosomal 18S rDNA and the ITS cistron indicated loss of historical ribosomal repeats. Phylogenetic analysis of a low-copy nuclear gene, GBSSI-1, indicated that some lineages maintained three copies of the locus, while others have lost one or two copies. CONCLUSIONS: Although island endemic lineages show chromosomal stasis, with no additional changes in chromosome number, they may undergo smaller-scale processes of gene loss and concerted evolution ultimately leading to further genome restructuring and downsizing.

Treatment Patterns, Survival, Quality of Life, and Healthcare Resource Use Among Patients With Triple-Class Refractory Multiple Myeloma in US Clinical Practice: Findings From the Connect MM Disease Registry.

BACKGROUND: Adults with triple-class refractory (TCR) multiple myeloma (MM) have limited treatment options and poor prognosis, but the burden of TCR MM has not been well characterized. This study evaluated treatment patterns, overall survival (OS), health-related quality of life (HRQoL), and healthcare resource use (HCRU) among patients with TCR MM in US clinical practice. PATIENTS AND METHODS: Patients with TCR MM in the Connect MM Registry (NCT01081028; a large, US, multicenter, prospective observational cohort study of patients with newly diagnosed MM) were included. Patient characteristics, treatment patterns, HRQoL, and HCRU were analyzed using descriptive statistics. OS was calculated using Kaplan-Meier methodology for the overall cohort and for patients with/without ≥1 post-TCR line of therapy (LOT). RESULTS: A total of 232 patients with TCR MM were included; 155 (67%) had ≥1 post-TCR LOT (post-TCR-Treated subgroup; median 9.9 months of follow-up). Most common post-TCR treatments were carfilzomib (47%), pomalidomide (40%), and daratumumab (26%); median treatment duration was 3.3 months. Median OS was 9.9 months in the overall population, 10.8 months in post-TCR-Treated patients, and 2.6 months for those with no new post-TCR LOT. HRQoL deteriorated and pain increased over 1 year of follow-up, with clinically meaningfully changes in EQ-5D (mean, -0.06 points) and FACT-G (mean, -9.9 points). 124 (53%) patients had ≥1 all-cause hospitalization and 58 (25%) had ≥1 MM-related hospitalization; median annualized length of stay was 35.3 and 42.9 days, respectively. CONCLUSION: The burden of TCR MM is substantial, emphasizing the need for more effective treatment options in the TCR setting.

Highly cellular leiomyoma - A great histopathological masquerader of endometrial stromal sarcoma.

ABSTRACT: Leiomyoma is the most common benign uterine tumor, whereas endometrial stromal tumors are rare uterine tumors with limited clinical experience. The distinction between highly cellular leiomyoma and endometrial stromal sarcoma can pose a diagnostic challenge to the pathologists as both these tumors have considerable overlapping features on histology.

Association of COVID-19 Real-Time Reverse Transcription-Polymerase Chain Reaction (RT-PCR) Cycle Threshold Value With Surrogate Markers of Disease Severity.

Introduction The cycle threshold (Ct) value in real-time reverse transcription-polymerase chain reaction (RT-PCR) serves as a criterion to diagnose coronavirus disease 2019 (COVID-19) and is inversely proportional to viral load. Levels of inflammatory markers such as aspartate aminotransferase (AST), ferritin, D-dimer, high sensitivity C-reactive protein (hs-CRP), and lactate dehydrogenase (LDH) are used as quantitative measures of COVID-19 severity. We examined the association between these markers and Ct values. Methodology This retrospective data analysis included 400 patients with positive RT-PCR results for COVID-19 who were admitted to a tertiary care hospital. Clinical and biochemical data were accessed from the hospital information management system. Associations of clinical parameters and markers of disease severity (e.g., polymorph, AST, hs-CRP, D-dimer, LDH, and ferritin levels) with Ct values were assessed. Observations LDH, ferritin, D-dimer, and hs-CRP were found to be significantly higher in moderate and severe groups than in the mild COVID-19 group. AST, ferritin, and hs-CRP levels were also significantly higher in severe COVID-19 subjects, compared to moderate COVID-19 subjects. Ct values for the E (envelop) gene and ORF (open reading frame) 1b gene were found to be significantly higher in those with severe COVID-19. Polymorph counts in subjects with Ct values of 25 or higher were significantly increased, compared to those with Ct values under 30. LDH, D-dimer, and hs-CRP levels in subjects with Ct values over 30 were significantly lower than for those with Ct values under 30. Ferritin was the best independent predictor of non-survival in study subjects, with an area under the curve (AUC) of 85.5% (95% confidence interval = 73.2-95.9). The Ct value for the E gene had an AUC of 75.1%, and the ORF1b gene had an AUC of 64.5%. However, no significant correlation was detected between any parameter and Ct value. Conclusion Polymorph, LDH, ferritin, D-dimer, and hs-CRP levels were significantly elevated in subjects with low E gene Ct values. Also, these subjects were at risk of severe disease and fatality. Ct values for the E gene thus could serve as an early indicator for patients at risk of severe disease and death.

Is Atrophic Nonunion a Misnomer - A Hospital-based Prospective Cross-Sectional Study.

Objective The present study was conducted to estimate histologically the proportion of avascularity of fracture ends in case of nonunion of long bones. Methods A total of 15 cases of established quiescent nonunion were operated according to the standard protocol and the fracture ends were evaluated histologically. The biopsied tissue was briefly fixed with formalin, embedded with paraffin (FFPE), and 5-micron sections were stained with hematoxylin and eosin according to standard protocols. Immunohistochemistry with anti-CD31 antibody (JC70A clone, DBS) was performed manually using standard protocols. Results All cases of quiescent nonunion were included; radiologically, 2 cases were oligotrophic, and 13 cases were of atrophic nonunion. A total of 20% of the patients were females, 40% were in the age group between 31and 40 years old, and, radiologically, all cases were of atrophic nonunion. All cases showed positivity for CD-31 on immunohistochemistry. The blood vessel density was category I in 13.33% of the cases and category II in 86.67% of the cases. Four cases presented with mild inflammation and two presented with moderate inflammation. The average vessel count was 10 per high power field in the age groups between 20 and 30, 31 and 40, and 41and 50 years old. The age group between 61 and 70 years old showed an average vessel count of 4 per high power field. The difference in the vessel counts of oligotrophic and atrophic nonunion was not significant. No correlation was observed in the density of vessel count and duration of nonunion Conclusion The nomenclature for the classification of nonunion into atrophic, oligotrophic, and hypertrophic needs revision. Our findings do not support that atrophic and oligotrophic nonunion are histologically different.

Is Atrophic Nonunion a Misnomer - A Hospital-based Prospective Cross-Sectional Study / Pseudoartrose atrófica é um termo incorreto? - Um estudo hospitalar transversal prospectivo

Abstract Objective The present study was conducted to estimate histologically the proportion of avascularity of fracture ends in case of nonunion of long bones. Methods A total of 15 cases of established quiescent nonunion were operated according to the standard protocol and the fracture ends were evaluated histologically. The biopsied tissue was briefly fixed with formalin, embedded with paraffin (FFPE), and 5-micron sections were stained with hematoxylin and eosin according to standard protocols. Immunohistochemistry with anti-CD31 antibody (JC70A clone, DBS) was performed manually using standard protocols. Results All cases of quiescent nonunion were included; radiologically, 2 cases were oligotrophic, and 13 cases were of atrophic nonunion. A total of 20% of the patients were females, 40% were in the age group between 31and 40 years old, and, radiologically, all cases were of atrophic nonunion. All cases showed positivity for CD-31 on immunohistochemistry. The blood vessel density was category I in 13.33% of the cases and category II in 86.67% of the cases. Four cases presented with mild inflammation and two presented with moderate inflammation. The average vessel count was 10 per high power field in the age groups between 20 and 30, 31 and 40, and 41and 50 years old. The age group between 61 and 70 years old showed an average vessel count of 4 per high power field. The difference in the vessel counts of oligotrophic and atrophic nonunion was not significant. No correlation was observed in the density of vessel count and duration of nonunion Conclusion The nomenclature for the classification of nonunion into atrophic, oligotrophic, and hypertrophic needs revision. Our findings do not support that atrophic and oligotrophic nonunion are histologically different.

Resumo Objetivo O presente estudo estimou a proporção de avascularidade histológica das extremidades das fraturas em caso de pseudoartrose de ossos longos. Métodos No total, 15 casos de pseudoartrose quiescente estabelecida foram operados de acordo com o protocolo padrão e as extremidades da fratura foram avaliadas histologicamente. Em resumo, o tecido biopsiado foi fixado em formalina e embebido em parafina (FFPE); secções de 5 mícrons foram coradas com hematoxilina e eosina de acordo com os protocolos padrões. A imunohistoquímica com anticorpo anti-CD31 (clone JC70A, DBS) foi realizada manualmente segundo protocolos padrões. Resultados Todos os casos de pseudoartrose quiescente foram incluídos; 2 eram de pseudoartrose oligotrófica e 13 eram de pseudoartrose atrófica à radiologia. Destes, 20% eram de pacientes do sexo feminino, 40% de indivíduos entre 31 e 40 anos de idade e todos os casos eram de pseudoartrose atrófica à radiologia. Todos os casos eram positivos para CD-31 à imunohistoquímica. A densidade dos vasos sanguíneos era de categoria I em 13,33% dos casos e de categoria II em 86,67%. Quatro casos apresentavam inflamação branda e dois apresentavam inflamação moderada. O número médio de vasos era de 10 por campo de alta potência na faixa etária de 20 a 30, de 31 a 40 e de 41 a 50 anos. A faixa etária de 61 a 70 anos apresentava, em média, 4 vasos por campo de alta potência. A diferença nos números de vasos em pseudoarthroses oligotróficas e atróficas não foi significativa. Não houve correlação entre a densidade de vasos e a duração da pseudoartrose. Conclusão A nomenclatura de classificação da pseudoartrose em atrófica, oligotrófica e hipertrófica precisa ser revista. Nossos achados não indicam que a pseudoartrose atrófica e oligotrófica sejam histologicamente diferentes.

Tracing, Tracking and Treating COVID-19 Associated Rhino-Orbito Cerebral Mucormycosis (ROCM).

Surge in the number of mucormycosis cases following second wave of coronavirus disease-19 (COVID-19) infection posed several diagnostic and prognostic challenges. This study was aimed to describe clinical, diagnostic features and survival outcomes among patients of mucormycosis in post COVID-19 context. Retrospective chart review. This study included 44 COVID-19 positive screened cases who presented with clinical features suggestive of mucormycosis. Demography, clinical profile, diagnostic findings, and the treatment outcome are studied. Medical and surgical outcomes are summarised as frequencies and percentages. The reliability of microbiological, and radiological findings against the pathological findings was analyzed using Kappa statistics (k). Based on constellation of microbiological, pathological and radiological findings 28 cases (63%) confirmed with mucormycosis infection. The mean (SD) age was 54.9 (12.9) years and two-third were males. The majority (90%) of cases presented with the feature of facial swelling, headache nasal blockade. Inpatient care for treatment of COVID-19 was recorded in 33 (75%). Diabetes mellitus was the commonest comorbidity in 27 (61.4%), 38 (86.4%) cases were treated by steroids and 30 (68.2%) were given oxygen therapy. There is a strong agreement (k = 0.83) between pathological and microbiological investigations. In thirty-eight cases (86.3%) remission was achieved when assessed after 8 weeks. Of the 44 cases, four patients died. The results of the current study suggest that the disease residues and/or recurrences in critical areas are frequent in mucormycosis. However, using the strategy of screening at risk patients, diagnosing, treating them with combination of antifungals, surgical debridement, and timely follow up may help in improving outcomes as compared to pre COVID-19 era.

Acute non-puerperal uterine inversion ascribed to malignant mixed Mullerian tumor of uterus: a rare presentation.

Non-puerperal uterine inversion is an extremely uncommon condition, and its occurrence due to malignant mixed Mullerian tumor (MMMT) of the uterus is quite exceptional. We report one such case of acute non-puerperal uterine inversion ascribed to MMMT in a 77-year-old postmenopausal woman. Such a case poses a diagnostic and management dilemma, and prior knowledge may result in a successful outcome.

Neutrophil-to-Lymphocyte Ratio as a Predictor of Disease Severity and Mortality in Coronavirus Disease 2019: Prospective Study From Central India.

BACKGROUND: Clinical presentation of coronavirus disease 2019 (COVID-19) varies from an asymptomatic state to severe disease characterized by acute respiratory distress syndrome, respiratory failure, thrombosis, and multi-organ dysfunction syndrome. The neutrophil-to-lymphocyte ratio (NLR) has been reviewed as one of the laboratory factors that have been proposed to predict the severity of disease and mortality in COVID-19 pandemic. AIM AND OBJECTIVES: To evaluate the association between NLR and the disease severity and mortality in COVID-19. MATERIALS AND METHODS: After approval from Institutional Ethics Committee, this prospective cohort study was carried out in a tertiary-care teaching medical institute of Central India. COVID-19 patients of the age group 18 years and above admitted during the study period were included. Cases were categorized into four groups as asymptomatic (Group A), mild (Group B), moderate (Group C), and severe (Group D) based on clinical symptoms, respiratory rate, oxygen saturation, and chest imaging. NLR was calculated by doing a complete blood count at the time of hospitalization by the Mindray BC-6000 auto hematology analyzer. The outcome of the disease was classified as recovery and death during hospitalization. Receiver operating characteristic (ROC) curve analysis was used to assess the ability of NLR at admission to predict severe COVID-19 or mortality. Ordinal regression analysis was used to assess the impact of NLR on disease severity and mortality. RESULTS: Mean NLR was significantly higher in the severe COVID-19 group as compared to the mild/moderate group and in deceased as compared to discharged cases. ROC curve analysis revealed NLR to be an excellent predictor of disease severity as well as a prognostic parameter for risk of death. NLR was found to be a significant independent positive predictor for contracting the severe disease (Odd's ratio 1.396, 95% CI=1.112-1.753, p=0.004) and mortality (Odd's ratio 1.276, 95% CI=1.085-1.499, p=0.003). CONCLUSION: High NLR was significantly associated with the disease severity and mortality in COVID-19.

Primary pleural liposarcoma: a rare differential for an opaque hemithorax.

Primary pleural liposarcoma (PPL) is a rare primary malignant pleural tumour originating from primitive mesenchymal tissue. We report the case of a 25-year-old man with a 6-week history of shortness of breath, cough, chest pain and hoarseness of voice. Chest X-ray showed a left opacified hemithorax, and thoracic CT scan revealed a large, heterogeneous, hypodense mass in the left hemithorax. The patient was taken up for ultrasound-guided core biopsy of the mass lesion, and histopathological examination revealed the diagnosis as a pleomorphic variant of PPL. We highlight the importance of considering PPL as a differential diagnosis in cases of large hemithoracic masses.

Evaluation of Histomorphological Parameters to Predict Occult Nodal Metastasis in Early-Stage Oral Squamous Cell Carcinoma.

OBJECTIVE: The oral squamous cell carcinoma (OSCC) treatment protocol depends upon lymph node metastasis. Elective neck dissection for early-stage OSCC (pT1/T2) elective neck dissection reduces the morbidity rate. It also reduces the overall survival and thus it becomes important to detect lymph node metastasis in early-stage OSCC. MATERIAL AND METHOD: Various histomorphological parameters have been studied to predict nodal metastasis in early-stage OSCC. We aim to evaluate these parameters in the context of nodal metastasis. 78 cases of early-stage OSCC were included in the study with histopathologic parameters like tumor size, grade, tumor depth of invasion (DOI), lymphovascular invasion (LVI), perineural invasion (PNI), worst pattern of invasion (WPOI), and lymph node level. RESULTS: Out of the 78 patients, 32 patients had lymph node metastasis. T stage, DOI, LVI, and WPOI showed statistically significant deviance from the null model (P-values of 0.007, 0.01, 0.04 and 0.02 respectively). The Odds Ratio (OR) of T stage, DOI, LVI and WPOI were 4.45 (95% C.I =1.47-14.1), 4.4 (95% C.I =1.32-15.88), 8.12 (95% C.I =1.002-198.20), and 3.39 (95% C.I =1.24-9.74) respectively. On multivariate analysis (Firth logistic regression) using DOI, LVI, and WPOI as independent variables, only T-stage and WPOI retained statistical significance. CONCLUSION: The prognostic information supplied by evaluating DOI, LVI, and WPOI warrants the inclusion of these parameters in the standard reporting format for all cases of OSCC.