Reappraisal of the anatomical diversities of the pyramidalis muscle with their potential clinical applicability: cadaveric analysis.

INTRODUCTION: The present study examined the morphology and morphometric parameters of the pyramidalis muscle (PM) in detail with their potential applicability in making midline infra-umbilical incisions and biomechanics of the linea alba. METHODS: PM was examined in 51 formalin-fixed cadavers (36 males and 15 females), and based on the mode of insertion or the level of apex, the formation or shape of the muscle was classified into nine types (Mori's classification). RESULTS: Bilateral PM was more prevalent (39.21%) than unilateral (1.96%) (p = 0.001). All the cases showed side symmetry except one. Mori's type 7 (right PM is higher apex and the left PM with elongated origin) was the most common form. The mean length of PM in males and females was 4.51 ± 0.14 and 3.33 ± 0.12 cm on the right and 4.51 ± 0.11 and 3.26 ± 0.16 cm on the left side. The mean width of right-sided PMs in males and females was 1.90 ± 0.17 and 1.58 ± 0.13 cm and left-sided 1.88 ± 0.14 and 1.55 ± 0.38 cm. The mean of pyramidalis-pubo-umbilical index (PPI) in males and females was 32.82 ± 1.65 and 27.50 ± 1.08, respectively. The mean insertion angle was 24.56 ± 3.07 on right side and 23 ± 2.03 on the left side (p = 0.03). Male predominance existed on right- and left-sided PM length (p < 0.001 and p < 0.001), width (p = 0.001) and PPI (p = 0.001). The strong positive correlation (r = 0.83) between length and width indicates a symmetrical muscle augmentation in the two dimensions. CONCLUSION: PM is an inconsistent anatomical structure with persistent morphology. The level and angle of insertion into the linea are crucial in the biomechanics of linea alba. PPI, determining the termination level would be useful to surgeons making midline infra-umbilical incisions.

Bartholin Gland Cyst Mimicking Rectocele: Common Pathology at an Uncommon Location.

Vaginal cysts are often encountered in gynaecological outpatient settings. These are usually asymptomatic in their initial course but become symptomatic when their size increases or they get infected. While evaluating such cases, clinical examination plays a vital role in ruling out their differential diagnoses. Imaging studies can complement clinical findings. However, in some instances, the nature of vaginal cysts may not be determined preoperatively until histopathology examination reveals it. We report here a rare case of a posterior vaginal wall cyst that presented as a mass protruding through the vagina. The clinical dilemma was the characterization of the cyst, owing to its huge size and rare location. The cyst was managed surgically by excision, and to our surprise, histopathological examination revealed it as a Bartholin gland cyst in the posterior vaginal wall, rare in its location.

Static and Dynamic Magnetic Resonance Imaging in Female Pelvic Floor Dysfunction: Correlation With Pelvic Organ Prolapse Quantification.

BACKGROUND: Pelvic organ prolapse (POP) is clinically assessed and staged commonly by the pelvic organ prolapse quantification (POP-Q) system. Dynamic magnetic resonance imaging (MRI) of the pelvic floor is an emerging modality for anatomical and functional assessment of the pelvic floor and staging of POP. The purpose of this study was to correlate the dynamic MRI findings with POP-Q examination for the staging of POP in each pelvic compartment by comparing various anatomic points. METHODS: A prospective observational study of the comparative cross-sectional design was conducted among patients who underwent MRI of the pelvic floor and POP-Q at our institute. A total of 50 patients were included. Anatomical landmarks in the three compartments were analyzed in relation to standard reference lines on dynamic MRI and compared with POP-Q measurements. RESULTS: Most of our patients had multicompartment disease (70%). When compared to POP-Q, MRI has a strong correlation for quantification of anterior (0.723) and middle (0.525) compartments and a weak correlation (0.232) for posterior compartment prolapse. CONCLUSION: POP-Q examination is based on the various points within the vaginal canal, and all the points do not represent a true anatomic landmark. MRI, on the other hand, is based on a true anatomical plane and gives detailed information about various structures in all three compartments. Thus, MRI also helps bridge the gap between various referring specialties in treating pelvic floor disorders.

"Effect of COVID-19 Vaccination on Menstrual Cycle Patterns of Reproductive-Age Women: A Multi-centric Observational Study."

AIM: The study was conducted to know the impact of COVID-19 vaccination on menstrual cycle patterns and pre- and post-menstrual symptoms in women aged 18-45 years. BACKGROUND: COVID-19 vaccination was introduced to combat the dreadful impacts of human coronavirus infection. The two indigenously developed COVID-19 vaccines approved for use in India are COVISHILED and COVAXIN. OBJECTIVES: To investigate the effects of COVID-19 vaccination on the menstrual cycle, pre- and post-menstrual symptoms and to establish the correlation with the type of vaccine received. METHODS: Multi-centric observational study conducted in six institutes of national importance in different states of India over one year. A total of 5709 female participants fulfilling inclusion criteria were enrolled. Data about the impact of vaccines (COVISHIELD and COVAXIN) and prior COVID-19 infection on the menstrual cycle and its associated symptoms were obtained using all participants' online and offline interviews. RESULTS: Of 5709 participants, 78.2% received COVISHIELD and 21.8% COVAXIN. Of the total 5709 participants, 333(5.8%) developed post-vaccination menstrual disturbances, with 32.7% having frequent cycles, 63.7% prolonged cycles, and 3.6% inter-menstrual bleeding. A total of 301 participants noticed changes in the amount of bleeding, with 50.2% excessive, 48.8% scanty, and 0.99% amenorrhea followed by heavy bleeding. Furthermore, the irregularities of the menstrual cycle (p=0.011) and length (0.001) were significantly higher in the COVAXIN group (7.2%) as compared to the COVISHIELD (5.3%) group. A total of 721 participants complained of newly developed/worsening pre- and post-menstrual symptoms. These symptoms were significantly higher in the COVISHIELD group (p=0.031), with generalized weakness and body pains as the main complaints (p=0.001). No significant difference was observed in the incidence of COVID-19 infection with these vaccines. No significant associations were observed when comparing menstrual abnormalities among those with COVID-19 infection (p>0.05). CONCLUSIONS: COVISHILED and COVAXIN vaccines were associated with menstrual cycle disturbances and pre-and post-menstrual symptoms in a small proportion of participants, with 94.7% having no change in the amount of bleeding during menstruation post-vaccination. The menstrual irregularities observed were significantly higher with the COVAXIN vaccine. Others: Further, long-term studies are required to confirm that the impact of COVID-19 vaccination on the menstrual cycle may be short-lasting, with no severe effects on women's menstrual health.

Correlation of Mid-Trimester Spot Urinary Albumin: Creatinine Ratio With the Adverse Pregnancy Outcome.

Background Urinary albumin creatinine ratio (ACR) is a known method of measurement of microalbuminuria. Microalbuminuria may be an early marker of endothelial dysfunction which can lead to various complications during the course of pregnancy. The objective of our study was to evaluate the correlation of mid-trimester spot urinary ACR with the pregnancy outcome. Material and methods We performed a prospective cohort study in the department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, Bhopal, for a period of one year. We studied 130 antenatal women between 14 and 28 weeks of gestation after obtaining written informed consent. The patients with ongoing urinary tract infection (UTI), pre-existing hypertension, or diabetes were excluded. Urinary samples were examined for spot ACR, and the women were followed until delivery. Primary maternal outcomes were development of gestational hypertension, pre-eclampsia, gestational diabetes mellitus (GDM), and preterm labour. Neonatal outcome was assessed in terms of birth weight, the APGAR (Appearance, Pulse, Grimace, Activity, Respiration) scores, and neonatal intensive care unit (NICU) admission. Results  In our study, mean urinary ACR was 19.07±12.94 mcg/mg and median urinary ACR (IQR) was 18 (9.43-25.25) mcg/mg. Prevalence of microalbuminuria in our study was 19.2%. It was observed that urinary ACR level was significantly higher in women with maternal complications like GDM, gestational hypertension, preeclampsia, and preterm labour. Also, mean urinary ACR of women who developed preeclampsia was higher (37.53±31.85) compared to women who developed gestational hypertension (27.40±9.71). Urinary ACR level was significantly higher in babies with low APGAR scores and in babies who needed NICU admission (p value < 0.05). The sensitivity and specificity of spot urinary ACR to predict GDM and preeclampsia were found to be good as calculated from the receiver operating curve. Conclusion We found definite correlation of higher values of mid-trimester urinary ACR with the adverse pregnancy outcome.

A Prospective Study on Correlation of First Trimester Crown-Rump Length With Birth Weight.

Background Ultrasound examination has been a crucial part of the evaluation of fetal health during pregnancy. It has become more accurate over the past few decades as a result of advances in radiodiagnostic imaging. While obstetric ultrasonography in the first trimester has been utilized extensively for gestational age assessment and confirmation of fetal viability, the imaging technique has seen little exposure in predicting pregnancy outcomes. This study was thus undertaken to find out any possible association between one of the first trimester parameters, i.e. crown-rump length (CRL) noted at the beginning of a pregnancy, and the birth weight of the neonate. Methods This prospective cohort study conducted at a teaching hospital in India spanning over a period of eighteen months included women with a spontaneously conceived intrauterine pregnancy at six to ten weeks period of gestation as calculated from the last menstrual period. Transvaginal sonography was performed for all such women and the CRL was noted. These CRL values were then compared to a standard nomogram and assigned to either of three categories i.e. CRL <5th centile, 5th to 95th centile, or >95th centile. The women were then followed up at the hospital with standard care till the end of their pregnancy, and finally, the birth weights were noted. Data were recorded in an MS Excel spreadsheet program and analysis was performed with regard to CRL in the first trimester and birth weights using SPSS v23 (IBM Corp.). Results Crown-rump lengths and birth weights of 104 cases were evaluated. The mean age of the study population was 26.6 years and the mean period of gestation (weeks) was 8.28 ± 1.01. The incidence of low birth weight (LBW) in the study was 22.1%. The distribution of LBW was significantly different between the three CRL categories (χ2 = 15.868, p = <0.001), being considerably higher in the CRL <5th centile category. No embryos with CRL >95th centile had low birth weight. Conclusions Our study suggested a congruence between the crown-rump length of an embryo noted in the first trimester and its weight at birth, with low birth weight being a fairly common occurrence in the deficient CRL category. This study highlights the role of a carefully performed first-trimester ultrasound examination in possibly predicting an adverse pregnancy outcome such as low birth weight and the probable inherent tendency of growth restriction in fetuses that are destined to develop the same.

Haematuria from early pregnancy in a morbidly adherent placenta: Case report and a short review.

The morbidly adherent placenta has evolved into one of the potentially life-threatening conditions in obstetrics. Vaginal bleeding is the most common presentation of placenta percreta. Other symptoms include unusual dull, prolonged lower abdominal pain. Although haematuria is rare, it may be a presentation of the morbidly adherent placenta in early pregnancy. We report a case of placenta percreta with a very uncommon presentation of gross haematuria early in the second trimester managed successfully. It is emphasized that a high index of suspicion, ultrasound, and/or MRI can establish a preoperative diagnosis of the invasive placenta earlier. However, the diagnostic accuracy of cystoscopy is still under debate. With timely diagnosis, preparedness, and multidisciplinary care, it is possible to minimize catastrophic complications.

Evaluation of Hormonal Profile and Ovarian Morphology among Adolescent Girls with Menstrual Irregularities in a Tertiary Care Centre at Central India.

Menstrual disturbances are common among adolescents with a prevalence rate of 11.3-26.7%. The most frequent menstrual irregularities are oligomenorrhea, menorrhagia, polymenorrhoea, and hypomenorrhea. PCOS (polycystic ovarian syndrome) is now recognized as the most prevalent endocrine disorder among the women of reproductive age. The current study was planned to evaluate socio-demographic factors, endocrine profiles, and ovarian morphology among adolescent girls with menstrual irregularities and compare these parameters in different phenotypes of adolescent PCOS cases. It is a hospital-based cross-sectional study among 248 adolescent girls (10-19 years) with menstrual irregularities. After obtaining informed consent, history and clinical examination findings were recorded on preform proforma. All girls were assessed on day 2/3 of the menstrual cycle for hormonal profile (serum TSH, FSH, LH, prolactin, and serum testosterone) and ovarian morphology (by transabdominal ultrasonography). All participating girls were divided into three groups (groups 1, 2, and 3) corresponding to phenotypes A, B, & D as per the Rotterdam criteria. In the study, oligomenorrhea was the most common menstrual disorder (70.97%). Biochemical hyperandrogenism and thyroid dysfunction were reported in 14.91% and 8.46% of girls, respectively. Our study noted that phenotype D ,i.e., group 3 (MI + PCOM-HA; 49.43%) was the most common phenotype in the study. In a comparative analysis of different groups, significant differences (p < 0.05) in hormonal and metabolic parameters showed highest in group 2, which represents phenotype B of PCOS (hyperandrogenic anovulation). This analysis revealed that adolescent hyperandrogenism (phenotypes A and B) is associated with a more deranged hormonal and metabolic profile than nonandrogenic PCOS (phenotype D). To prevent long-term sequelae, lifestyle changes, early treatment, and close follow-up are recommended in this subset of girls.

Burden and Associated Genotype Patterns of High-Risk Human Papilloma Virus Infection and Cervical Cytology Abnormalities among Women in Central India.

Background: The epidemiology of human papilloma virus (HPV) infection and the pattern of HPV genotype distribution are much-needed parameters to assess the risk of cervical cancer among females. However, due to less availability of data on HPV burden and its genotypes from various geographical regions in India makes cervical cancer screening modalities and vaccination strategies difficult to implement. Objective: The present study was conducted to identify the various genotypes particularly high-risk HPV types in premalignant or malignant cervical lesions. Methods: The study was a hospital-based cross-sectional study wherein 295 symptomatic women were screened by Pap smear and multiplex real-time PCR was performed for HPV genotypes identification in women with abnormal cervical cytology. Results: Out of 295 women, 237 (80.3%), 45 (15.3%), and 13 (4.4%) women had normal Pap smear, squamous cell carcinoma and precancerous cytology, respectively. Among these 58 women having abnormal cervical cytology, HPV was detected in 48 (81.0%) participants. Most common HPV genotypes in our study were HPV 16 (n = 29; 60.4%) followed by mixed infections; i.e., more than one type of HPV was detected (n = 10, 20.8%). HPV 18 was detected only in 6.25%, whereas other high-risk HPV genotypes were found to be 12.5%. Conclusion: HPV positivity was >80% in women having abnormal Pap smear. The prevalence of HPV 18 was found to be much less in Central India, compared to other parts of country. HPV 16 was the most common genotype followed by mixed HPV genotype infections. It is evident from our study that symptomatic women even if having normal Pap smear should be screened for HPV and followed up with periodic Pap smears for detecting any change in cervical cytology, thus preventing cervical cancer in women.

Burden of congenital rubella syndrome (CRS) in India based on data from cross-sectional serosurveys, 2017 and 2019-20.

BACKGROUND: India has set a goal to eliminate measles and rubella/Congenital Rubella Syndrome (CRS) by 2023. Towards this goal, India conducted nationwide supplementary immunization activity (SIA) with measles-rubella containing vaccine (MRCV) targeting children aged between 9 months to <15 years and established a hospital-based sentinel surveillance for CRS. Reliable data about incidence of CRS is necessary to monitor progress towards the elimination goal. METHODS: We conducted serosurveys in 2019-20 among pregnant women attending antenatal clinics of 6 hospitals, which were also sentinel sites for CRS surveillance, to estimate the prevalence of IgG antibodies against rubella. We systematically sampled 1800 women attending antenatal clinics and tested their sera for IgG antibodies against rubella. We used rubella seroprevalence data from the current survey and the survey conducted in 2017 among antenatal women from another 6 CRS surveillance sites to construct a catalytic models to estimate the incidence and burden of CRS. RESULT: The seroprevalence of rubella antibodies was 82.3% (95% CI: 80.4-84.0). Rubella seropositivity did not differ by age group and educational status. Based on the constant and age-dependent force of infection models, we estimated that the annual incidence of CRS in India was 225.58 per 100,000 live births (95% CI: 217.49-232.41) and 65.47 per 100,000 live births (95% CI: 41.60-104.16) respectively. This translated to an estimated 14,520 (95% CI: 9,225-23,100) and 50,028 (95% CI: 48,234-51,543) infants with CRS every year based on age-dependent and constant force of infection models respectively. CONCLUSIONS: Our findings indicated that about one fifth of women in the reproductive age group in India were susceptible for rubella. The estimates of CRS incidence will serve as a baseline to monitor the impact of MRCV SIAs, as well progress towards the elimination goal of rubella/CRS.

A clinical study to identify the possible etiology of complex partial seizures using magnetic resonance imaging brain findings and its implications on treatment.

CONTEXT: Epilepsy is one of the common neurological disorders worldwide. Fundamentally, there are two types of epilepsy-primary generalized epilepsy and localization-related epilepsy. Partial seizures account for about 40% of childhood seizures in some series and can be classified as simple or complex.[1] Partial seizures, more so the complex partial seizures (CPSs), are presumed to have a structural etiology. AIMS: (1) To study the magnetic resonance imaging (MRI) brain findings in CPSs in children aged 1-18 years. (2) To identify treatable causes of CPSs based on MRI findings and institute appropriate treatment. STATISTICAL ANALYSIS: Statistical analysis was performed using percentages and proportions. METHODS: Hospital based prospective study in which MRI brain was done on all newly diagnosed children with complex partial seizures, aged 1 to 18 yrs, during the study period. Final diagnosis was made correlating clinical features, radiological features and other supportive evidences, and appropriate treatment instituted. Follow up of cases was done until the completion of treatment (maximum 6 months). RESULTS: Among the 64 children who were clinically diagnosed to have CPSs and subjected to MRI study of the brain, 40(62.5%) children were detected to have structural lesions, of which neurocysticercosis (NCC) was noted in 17 (42.5%), tuberculoma in 12 (30%), hippocampal sclerosis (HS) in 6 (15%), gliosis in 4 (10%), and tumor in 1 (2.5%) patient. Sixty-two (96.8%) children were treated medically, and 2 (3.2%) children underwent surgery. CONCLUSIONS: Etiology of CPS based on MRI findings showed a substantial number of medically- and surgically-treatable pathologies. This study done on South Indian children showed neuro infections to be the most common cause of CPS, followed by HS, with NCC being the most common lesion noted. MRI not only identifies specific epileptogenic substrates, but also determines the specific treatment and predicts prognosis and should be the imaging modality of choice in the evaluation of CPS.

Symplastic leiomyoma of uterus--a clinico-pathological dilemma.

The diagnosis of uterine smooth muscle tumours is usually not difficult. Occasionally, benign tumours with an unusual histopathology may cause some dilemma for clinicians who had not experienced such report before. A 50-year-old female patient was admitted to our gynaecology clinics with lower abdominal heaviness and urinary symptoms and undergone total abdominal hysterectomy with bilateral salpingo-oophorectomy with a probable diagnosis of cervical fibroid. Histopathological examination showed lipoleiomyoma uterus with focal symplastic features. This case report describes the clinic-pathological dilemma in managing the patient with symplastic leiomyoma of the uterus.

Hormone receptor and c-ERBB2 status in distant metastatic and locally recurrent breast cancer. Pathologic correlations and clinical significance.

Estrogen receptor (ER), progesterone receptor (PR), and c-ERBB2 (HER2/neu) are therapeutically and prognostically important markers in the management of breast carcinoma. They are not always analyzed in distant metastatic and locally recurrent breast cancers. We compared immunohistochemical expression in a series of primary breast carcinomas with their distant metastases (n = 72) and local recurrences (n = 45) and analyzed the impact of any changes on survival. Discordance rates between primary and metastatic and between primary and locally recurrent lesions, respectively, were 18% (13/72) and 13% (6/45) for ER, 42% (30/72) and 33% (15/45) for PR, and 7% (5/72) and 2% (1/45) for c-ERBB2. There was statistically significant discordance between primary and metastatic PR status (P = .017; kappa = 0.201). Among locally recurrent tumors, 15 (33%) of 45 revealed discordance for PR (P = .006; kappa = 0.366). We observed a trend for shorter survival among women with ER- metastatic and locally recurrent tumors regardless of the primary tumor ER status. Our findings suggest a benefit for routine evaluation of ER, PR, and c-ERBB2 status in distant metastatic and locally recurrent breast cancer for therapeutic and prognostic purposes.

Pattern of skeletal injuries in cases of falls from a height.

Differentiating the injuries exclusively due to falls from a height is difficult if no proper history is provided. Some clinical studies and case reports have been published on the subject, but an autopsy-based approach to the subject is missing in the literature of recent decades. A retrospective study was carried out on 80 cases of fatal falls from a height brought for autopsy. In selected instances police reports, suicide notes, medical records and scene photographs were reviewed. The principal aim was to look for a pattern of skeletal injuries formed as a result of falls from a height. The majority of the victims were male, aged between 20-30 years and labourers by occupation. Most of them fell from a height of 0-10 feet. The head is the most vulnerable structure with fractures of the vertex being common. As the height of falls increases, fractures of the ribs and sternum are also found. Finally, it is concluded that falls on the head are more likely and the most fatal of all. However, it cannot be taken as a sole indicator of the manner of death. Risk assessment should be carried out before any work at a height is undertaken.

Myocardial antioxidant status and oxidative stress after combined action of exercise training and ethanol in two different age groups of male albino rats.

The interaction of exercise training and ethanol on the myocardial antioxidant enzymes and the oxidative stress markers was investigated in the Wistar strain male albino rats. We also tested the interactive effects of exercise training and ethanol on the age-associated free radical production and antioxidant defense system. We found a significant decrease (p<0.05) in the activity levels of superoxide dismutase (SOD) and catalase (CAT) in the myocardium of old rats when compared to young rats by 26% and 58%, respectively, suggesting the onset of age-dependent decrease in the myocardial antioxidant enzyme system. In contrast to the decreased antioxidant enzyme activity, xanthine oxidase (XOD) and lipid peroxidation (LPO) levels were elevated, suggesting the age-induced oxidative stress. Exercise training significantly (p < 0.05) elevated the activities of SOD, CAT, XOD and LPO levels in both the age groups of animals. Ethanol consumption significantly lowered the SOD and CAT activities in both the age groups, whereas a significant increase was observed in the XOD and LPO levels. In contrast, the combination of exercise training plus ethanol lowered XOD and LPO levels in both the age groups of rats compared to ethanol treated rats. A significant (p < 0.05) increase in the activities of SOD and CAT was reported in the rats treated with the combination of exercise training plus ethanol. This increase was more pronounced in the younger rats than the older rats. The findings of the present investigation on the potential role of antioxidant enzymes to counter the ethanol-induced pro-oxidants showed an increase with the interaction of exercise training. With age, a decrease in the antioxidant enzyme capacity was observed. This reveals that the old age rats were more affected to the pro-oxidants when compared to the young age rats. In conclusion it is demonstrated that two months treadmill endurance exercise training is beneficial to both young and old rats in improving antioxidant defense to challenge the oxidative stress in the myocardial tissue and thereby successfully countering the free radical production due to ethanol intoxication.

Generalised cutis laxa.

A 44-year-old man presented with generalised progressive lax skin of 14 years duration associated with dysphagia, joint pains and hoarseness of voice. Examination revealed "blood hound" like facies, lox skin with loss of elasticity, dilated tortuous superficial vessels over extremities and back. Systemic involvement noted were oesophageal and pharyngeal diverticuli, inguinal hernia and dermatochalasis. Skin biopsy using Verhoeff Van Gieson's stain was suggestive of cutis laxa.

Extensive squamous metaplasia in nodular goiter--a diagnostic dilemma in the fine needle aspiration (FNA) cytology--a case report.

Metaplastic changes are commonly found at widespread locations occurring in both reactive and neoplastic conditions. They can simulate tumors histologically. Squamous metaplasia is rarely seen in areas of fibrosis and inflammation secondary to hemorrhage in nodular goiters. If it is extensive with associated degenerative changes and present clinically in the form of a nodule, cytopathologist must take care to differentiate this from primary or metastatic squamous cell carcinoma or even anaplastic carcinoma.