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Background and Aims: Systemic sclerosis is an autoimmune disease, of which cutaneous sclerosis is a cardinal feature. Other skin manifestations include Raynaud's phenomenon, digital ulcers, gangrene, flexion contractures, and telangiectasias. It has been noted that the clinical and antibody profile varies within ethnic groups. The objective of the study was to study the clinical profile of patients with systemic sclerosis in a tertiary center in South India and to compare to other ethnic groups. Materials and Methods: Thirty-five patients were recruited in the study period between February 2014 and September 2015. A record of the disease details, systemic manifestations, morphology, and distribution of the cutaneous manifestations and investigations were done by the principal investigator. The severity of cutaneous sclerosis was assessed by modified Rodnan Skin Score (mRSS). Results: Our study had a female preponderance with diffuse type of disease in 91% of patients. The common cutaneous presenting complaints were sclerosis (n = 35, 100%), Raynaud's phenomenon (n = 25, 71.4%), and pigmentary disturbances (n = 33, 94.3%). Respiratory system was the most common system involved, with interstitial lung disease seen in 78.1% (n = 25). A significant association (P = 0.026) was noticed between the increase in mRSS and interstitial lung disease. Conclusion: Pigmentary disturbances were higher in our population, whereas Raynaud's phenomenon, digital ulcers, and telangiectasia were less common than in Western population. A significant association (P = 0.026) was found between mRSS and interstitial lung disease.

Introduction: Nail fold dermoscopy is a noninvasive technique which aids in the diagnosis of systemic sclerosis. It also helps in predicting the extent and stage of microvascular damage. There are only a few studies describing the pattern of nail fold capillaries in systemic sclerosis in the Indian population. Objectives: To study the patterns of nail fold capillaries using a hand-held dermoscope and to correlate these findings with cutaneous and systemic manifestations in patients with systemic sclerosis. Methods: Thirty-five patients were recruited in the study period between February 2014 and September 2015. All patients with systemic sclerosis were examined for cutaneous manifestations and dermoscopy of the nail fold capillaries was performed using Heine delta 20 dermoscope. Results: Our study had a female preponderance with the diffuse type of disease in 91% of patients. The most common abnormal nail fold dermoscopic pattern was dilated capillaries (91%). Scleroderma pattern was seen in 77% of our patients with the most common being active pattern. Early, active, and late type of the capillary pattern were associated with increased duration of disease but was not statistically significant. There was no significant association between capillary pattern and systemic manifestations. Conclusions: Majority (77%) of our patients had scleroderma patterns of which the active scleroderma pattern was the most common. There was no significant association between capillary pattern and systemic manifestations.

Anti-transcription intermediary factor-1 γ (TIF-1 γ) antibody is a myositis-specific antibody. These cases had specific clinical features in the past studies. There is no published data on such patients from South Asia. We retrospectively looked at data from patients with positive anti-TIF-1 γ antibodies from our hospital database between May 2019 and October 2020. Their clinical presentation, muscle and extra muscular involvement, investigations, presence of malignancy, and treatment with subsequent follow-up were retrieved using the electronic medical records. TIF-1 γ was rare at our center and was 2.46% out of the total positive myositis immunoblot results. Seven adult patients had significant anti-TIF-1 γ positivity. Five out of them had clinical muscle weakness; none had severe or respiratory muscle weakness. No patients had cancer-associated myositis. The skin was the most common extra muscular organ involved. The absence of cancer-associated myositis with anti-TIF-1 γ subjects in our series may represent the difference in phenotype in the South Asian population.

Purpose: The purpose of the study was to compare the efficacy of two vertically integrated teaching–learning methods, a peer-led ocular basic science workshop (OBSW) versus lecture by ophthalmology faculty, in enhancing the underlying basic science knowledge and examination skills of ophthalmic clinical tests among second clinical year medical students. Design: This was a prospective, interventional comparative study. Students were randomly assigned to peer-led OBSW and interactive lecture-based method of teaching by a faculty. Change in knowledge was assessed using pre and post multiple-choice question test score. Quantitative assessment of clinical examination skills between the two groups was done using objective structured clinical examination (OSCE) at 2-week postintervention. All assessors were blinded. Student's attitude toward the teaching–learning methods was assessed using a 5-point Likert scale. Setting: This study was conducted in the departments of ophthalmology, anatomy, and physiology of a tertiary care medical college in southern India. Participants: Second clinical year students starting their ophthalmology rotation, 5 peer teachers, and 47 students were recruited. All completed the study. Results: Post intervention, there was a significant change in basic science knowledge from baseline among both the arms. Mean improvement in posttest score immediately following the OBSW was 9.25 (standard deviation [SD]: 3.34, 95% confidence interval (CI): 7.84–10.66, t = 13.57, P = 0.00) and 7.83 (SD: 3.66), 95% CI: 6.24–9.41, t = 10.24, P = 0.00) after the lecture. The improvement in scores continued in the 2-week posttest scores. There was no statistically significant difference in the OSCE scores between the two groups. Conclusions: The vertically integrated OBSW and lecture methods were equally effective in improving knowledge and clinical skills of basic ocular examination skills among the second clinical year medical students.

Background & objectives: The pathological hallmark of scrub typhus infection is focal or disseminated vasculitis. As with other infections, antinuclear antibodies (ANA) have been previously described in scrub typhus. However, the underlying mechanisms and implications of this immunological phenomenon is not well understood. In the present work it was assessed whether ANA is associated with illness severity and outcomes. Methods: In this prospective study spanning one year, patients fulfilling the diagnostic criteria for scrub typhus were recruited. Patients with other acute infective febrile illnesses were taken as controls. ANA positivity was compared between the cases and controls. ANA in scrub typhus was assessed for correlation with disease severity, organ dysfunction and outcomes. Results: The cohort comprised of 149 patients (scrub 89; controls 60) with mean age 46.5 (SD=16.9) yr; 48.3% were female. ANA was detected in 48 (53.9%) patients with scrub typhus and 9(15%) controls (p < 0.001). The ANA pattern was predominantly speckled (93.8%) in both scrub typhus patients and controls. In patients with scrub typhus, ANA positivity was associated with increasing APACHE-III score [Odds ratio (OR) 1.01; 95% CI 0.99–1.03; p = 0.09]. On bivariate analysis, ANA tended to be correlated with acute respiratory distress syndrome (OR 2.32; 95% CI 0.98–5.46; p = 0.06), hepatic dysfunction (OR 2.25; 95% CI 0.94–5.39, p = 0.06) and aseptic meningitis (OR 6.83; 95% CI 0.80–58.05, p = 0.08). The presence of these antibodies did not correlate with duration of hospitalization or mortality. Convalescent sera on 31 ANA positive scrub typhus patients demonstrated persistence of ANA in only 5 (16.1%) patients. Interpretation & conclusion: The disappearance of ANA during the convalescent phase suggests that ANA is expressed during the acute phase of scrub typhus infection. Its association with organ dysfunction warrants further study of the mechanisms and impact of autoantibody formation in scrub typhus.

Context: There is heterogeneity in the clinical behavior of breast carcinoma patients with node negativity. Studies have analyzed different factors influencing the outcome in such patients. It is suggested that the presence of nodal micrometastasis can act as a tool in predicting the aggressiveness of these tumors. Aims: The aim of this study is to assess the yield of micrometastasis/isolated tumor cell (ITC) by ultrastaging the morphologically negative axillary nodes and staining them with immunohistochemistry for epithelial membrane antigen. The association of such metastasis with the clinical outcome is determined. Settings and Design: This was a retrospective analytical study. One hundred cases of node-negative breast carcinoma patients who underwent surgery along with axillary lymph node dissection were selected. Materials and Methods: The largest node from the axillary dissection was selected and subjected to ultrastaging and immunohistochemical staining (as sentinel node dissection was not a routine practice at that time), to look for occult metastasis in the form of micrometastasis or ITCs. Statistical Analysis: Occurrence of events in the form of recurrence or death was noted. Association of the parameters was analyzed using Fisher's exact test. Results: Among the 100 cases, 79 patients were followed up for a minimum period of 5 years. Two cases had micromets in one node each. These two patients were among the eight, who developed events subsequently (25%). Hence, a statistically significant association was found between the presence of micromets with events. Conclusions: There is a statistically significant association between the presence of micromets and disease recurrence. Hence, we suggest that ultrastaging of the negative axillary node (now sentinel node, as it is being routinely done) might prove effective in predicting the events/prognosis in clinically and morphologically node-negative breast carcinoma patients

Etiologic diagnosis of an eosinophilic pleural effusion (EPE) presents a diagnostic challenge when intrapleural air and blood have been ruled out as its proximate causes. Among the causes of EPE, those that require immunosuppression for the underlying disease include connective tissue diseases, sarcoidosis, vasculitis, and eosinophilic pneumonia. We present a case of clinically suspected Behcet's syndrome based on a 10-year history of recurrent multiple oral ulcers and human leukocyte antigen-B51 positivity who presented with only an EPE. Computed tomography pulmonary angiogram ruled out central thoracic vein thrombosis but was inconclusive in ruling out a subsegmental pulmonary embolism. The patient declined immunosuppressants and while on follow-up developed bilateral extensive acute lower limb deep venous thrombosis and pulmonary embolism. Upper infrarenal inferior vena cava demonstrated chronic thrombosis suggestive of its antecedent role in pulmonary embolism-related EPE during the first instance. Behcet's syndrome-related EPE can be associated with venous thromboembolism, and immunosuppressive therapy prevents the subsequent thrombotic episodes.

Background: Thoracoscopic oesophageal mobilisation during a minimally invasive oesophagectomy (MIE) is most commonly performed with the patient placed in the lateral decubitus position (LDP). The prone position (PP) for thoracoscopic oesophageal mobilisation has been proposed as an alternative. Materials and Methods: This was a retrospective, comparative study designed to compare early outcomes following a minimally invasive thoracolaparoscopic oesophagectomy for oesophageal cancer in LDP and in PP. Results: During the study period, between January 2011 and February 2014, 104 patients underwent an oesophagectomy for cancer. Of these, 42 were open procedures (transhiatal and transthoracic oesophagectomy) and 62 were minimally invasive. The study group included patients who underwent thoracolaparoscopic oesophagectomy in LDP (n = 23) and in PP (n = 25). The median age of the study population was 55 (24-71) years, and there were 25 males. Twenty-one (21) patients had tumours in the middle third of the oesophagus, 24 in the lower third, and 3 arising from the gastro-oesophageal junction. The most common histology was squamous cell cancer (85.4%). The median duration of surgery was similar in the two groups; however, the estimated median intraoperative blood loss was less in the PP group [200 (50-400) mL vs 300 (100-600) mL; P = 0.01)]. In the post-operative period, 26.1% patients in the LDP group and 8% in the PP group (8%) developed respiratory complications. The incidence of other post-operative complications, including cervical oesophagogastric anastomosis, hoarseness of voice and chylothorax, was not different in the two groups. The T stage of the tumour was similar in the two groups, with the majority (37) having T3 disease. A mean of 8 lymph nodes (range 2-33) were retrieved in the LDP group, and 17.5 (range 5-41) lymph nodes were retrieved in the PP group (P = 0.0004). The number of patients with node-positive disease was also higher in the PP group (19 vs 10, P = 0.037). Conclusion: MIE in the PP is an effective alternative to LDP. The exposure obtained is excellent even without the need for a complete lung collapse, thereby obviating the need for a double-lumen endotracheal tube. A more meticulous dissection can be performed resulting in a higher lymph nodal yield.

Pyoderma gangrenosum (PG) is a rare disease and that affecting specifically the sole of the foot, is even rarer. Here, we report the case of a 54-year-old female admitted with a painful ulcer on the sole of the right foot which was initially treated with empirical antibiotics and debridement. The disease was found to spread rapidly after each debridement. The culture reports were negative; rheumatology workup and Doppler study were within normal limits. A clinical suspicion of PG was made and was confirmed with tissue biopsy. She was started on oral steroids following which she dramatically improved. Thus, when a patient presents with a rapidly expanding painful ulcer in a vascular limb that is refractory to antibiotic treatment and exacerbating on debridement, it is imperative to consider the possibility of PG.

Context: Pancreatic necrosis is a local complication of acute pancreatitis. The development of secondary infection in pancreatic necrosis is associated with increased mortality. Pancreatic necrosectomy is the mainstay of invasive management. Aims: Surgical approach has significantly changed in the last several years with the advent of enhanced imaging techniques and minimally invasive surgery. However, there have been only a few case series related to laparoscopic approach, reported in literature to date. Herein, we present our experience with laparoscopic management of pancreatic necrosis in 28 patients. Materials And Methods: A retrospective study of 28 cases [20 men, 8 women] was carried out in our institution. The medical record of these patients including history, clinical examination, investigations, and operative notes were reviewed. The mean age was 47.8 years [range, 23-70 years]. Twenty-one patients were managed by transgastrocolic, four patients by transgastric, two patients by intra-cavitary, and one patient by transmesocolic approach. Results: The mean operating time was 100.8 min [range, 60-120 min]. The duration of hospital stay after the procedure was 10-18 days. Two cases were converted to open (7.1%) because of extensive dense adhesions. Pancreatic fistula was the most common complication (n = 8; 28.6%) followed by recollection (n = 3; 10.7%) and wound infection (n = 3; 10.7%). One patient [3.6%] died in postoperative period. Conclusions: Laparoscopic pancreatic necrosectomy is a promising and safe approach with all the benefits of minimally invasive surgery and is found to have reduced incidence of major complications and mortality.

Background: Motor vehicle crashes and falls account for most of the spine fractures with subsequent serious disability. Aim: To define the incidence, causes, and outcome of spinal fractures. Materials and Methods: Data were collected retrospectively from trauma registry database of all traumatic spinal injuries admitted to the section of trauma surgery in Qatar from November 2007 to December 2009. Results: Among 3712 patients who were admitted to the section of trauma surgery, 442 (12%) injured patients had spinal fractures with a mean age of 33.2 ± 12 years. The male to female ratio was 11.6:1. Motor vehicle crashes (36.5%) and falls from height (19.3%) were the leading causes of cervical injury (P = 0.001). The injury severity score ranged between 4 and 75. Nineteen percent of cases with cervical injury had thoracic injury as well (P = 0.04). Lumber injury was associated with thoracic injury in 27% of cases (P < 0.001). Combined thoracic and lumber injuries were associated with cervical injury in 33% of cases (P < 0.001). The total percent of injuries associated with neurological deficit was 5.4%. Fifty-three cases were managed surgically for spine fractures; 14 of them had associated neurological deficits. Overall mortalityrate was 5%. Conclusions: Spine fractures are not uncommon in Qatar. Cervical and thoracic spine injuries carry the highest incidence of associated neurological deficit and injuries at other spinal levels. Young males are the most exposed population that deserves more emphasis on injury prevention programs in the working sites and in enforcement of traffic laws.

Background: Halitosis has been correlated with the concentration of volatile sulfur compounds (VSCs) produced in the oral cavity by metabolic activity of bacteria colonizing the periodontal pockets and the dorsum of the tongue. It has been assumed that there is a relationship between periodontal disease and diabetes mellitus. Objectives: The aim of the study was to assess the malodor using the organoleptic method and tanita device; to quantify odoriferous microorganisms of subgingival plaque and tongue coating, such as P. gingivalis (Pg), T. forsythia (Tf), and F. nucleatum (Fn) using polymerase chain reaction (PCR) in nondiabetic and diabetic chronic periodontitis patients. Patients and Methods: Thirty chronic periodontitis patients (with and without diabetes) with 5-7 mm pocket depth, radiographic evidence of bone loss, and presence of oral malodor participated in this study. Subjective assessment of mouth air was done organoleptically and by using a portable sulfide monitor. Tongue coating was also assessed. Results: The scores of plaque index, gingival index, gingival bleeding index, VSC levels, and tongue coating between the nondiabetic and diabetic patients were not significant (P>0.5). In nondiabetic patients, Fn was found to be significantly (P0.5). In diabetic patients, Fn and Tf have shown significant (P

Nasolabial cyst, also known as Klestadt′s cyst is an uncommon nonodontogenic cyst. Bilateral nasolabial cysts are rarer and less than 10 cases have been reported in the literature. Diagnosis is usually clinical and they present as slow-growing swellings in the nasolabial region causing cosmetic deformity and nasal obstruction. A postpartum lady presented with bilateral swelling of the cheeks. Excision was done via a sublabial approach. She is asymptomatic one year after surgery. Nasolabial cysts are developmental but usually noticed after a trauma. There is no data relating the cysts to pregnancy.

BACKGROUND &OBJECTIVES : Malodour has been correlated with the concentration of volatile sulphur compounds produced in the oral cavity by metabolic activity of bacteria colonizing the periodontal sites and the dorsum of the tongue. The aim of this study was to detect malodour in mouth air organoleptically and using a portable sulphide monitor and to correlate it with the clinical parameters, halitosis linked toxins and BANA, using tongue and subgingival plaque samples. The halitosis grading is also correlated with the microbial colonies of the subgingival plaque sample. METHODS : 20 patients with chronic periodontitis with 5-7 mm pocket depth, radiographic evidence of bone loss and presence of oral malodour participated in this study. Assessment of mouth air was done organoleptically and by using a portable sulphide monitor. The clinical parameter, plaque index (PI), gingival index (GI), gingival bleeding index (BI), were obtained from all the areas. Samples for BANA and to detect halitosis linked toxins were taken from the dorsal surface of the tongue and periodontal pockets ranging 5-7 mm. Halitosis related microbial colonies were identified using anaerobic culturing from the subgingival plaque. RESULTS : The scores of PI, GI, BI and sample that tested positive for halitosis linked toxins and with the halitosis grading were not significant. The presence of tongue coating and the halitosis grading and toxin levels were significant. BANA has shown to be non contributory due to technical problems. Anaerobic culture has shown to identify Streptococcus, Bacteroides, Fusobacterium, Porphyromonas and Prevotella colonies. INTERPRETATION &CONCLUSION : The results confirmed that there was no correlation between the clinical parameters, halitosis linked toxins and halitosis grading. The microbial colonies have shown to correlate with the presence of oral malodour.