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ABSTRACT Children delivered by elective, prelabor Cesarean section (C-section) are not exposed to the birth canal microbiota and, in relation to vaginally delivered children, show altered microbiota development. Perturbed microbial colonization during critical early-life windows of development alters metabolic and immune programming and is associated with an increased risk of immune and metabolic diseases. In nonrandomized studies, vaginal seeding of C-section-born neonates partially restores their microbiota colonization to that of their vaginally delivered counterparts, but without randomization, confounding factors cannot be excluded. In a double-blind, randomized, placebo-controlled trial, we determined the effect of vaginal seeding versus placebo seeding (control arm) on the skin and stool microbiota of elective, prelabor C-section-born neonates (n = 20) at 1 day and 1 month after birth. We also examined whether there were between-arm differences in engraftment of maternal microbes in the neonatal microbiota. In relation to the control arm, vaginal seeding increased mother-to-neonate microbiota transmission and caused compositional changes and a reduction in alpha diversity (Shannon Index) of the skin and stool microbiota. The neonatal skin and stool microbiota alpha diversity when maternal vaginal microbiota is provided is intriguing and highlights the need of larger randomized studies to determine the ecological mechanisms and effects of vaginal seeding on clinical outcomes. IMPORTANCE Children delivered by elective C-section are not exposed to the birth canal and show altered microbiota development. Impairing microbial colonization during early life alters metabolic and immune programming and is associated with an increased risk of immune and metabolic diseases. In a double-blind, randomized, placebo-controlled trial, we determined the effect of vaginal seeding on the skin and stool microbiota of elective C-section born neonates and found that vaginal seeding increased mother-to-neonate microbiota transmission and caused compositional changes and a reduction in the skin and stool microbiota diversity. The reduction of neonatal skin and stool microbiota diversity when maternal vaginal microbiota is provided is intriguing and highlights the need of larger randomized studies to determine the ecological mechanisms and effects of vaginal seeding on clinical outcomes.

Corneal transplant is a procedure that aims to replace dysfunctional corneal tissue with a transparent graft and is one of the most widely performed transplant surgeries, but its public and professional awareness is low outside of ophthalmology. Corneal tissue consists of 5 major layers that serve to maintain its structural integrity and refractive shape: the epithelium, Bowman’s layer, the stroma, Descemet’s membrane, and the endothelium. Failure or irreversible damage to any layer of the cornea may be an indication for corneal transplant, and variants of this procedure may be full thickness or selectively lamellar. Complications related to corneal transplantation may occur anywhere from during surgery to years afterward, including rejection, dehiscence, cataract, and glaucoma. Complications should be managed by an ophthalmologist, but other physicians should be aware of prophylactic medications. Topical immunosuppressants and steroids are effective for preventing and treating rejection episodes, whereas there is little evidence to support the use of systemic immunosuppression. Eye protection is recommended for any corneal transplant recipient. Physicians should counsel patients on corneal donation, especially if outside the United States, where donor tissue is in short supply.

The meconium microbiome may provide insight into intrauterine and peripartum exposures and the very earliest intestinal pioneering microbes. Prenatal antibiotics have been associated with later obesity in children, which is thought to be driven by microbiome dependent mechanisms. However, there is little data regarding associations of prenatal or peripartum antibiotic exposure, with or without cesarean section (CS), with the features of the meconium microbiome. In this study, 16S ribosomal RNA gene sequencing was performed on bacterial DNA of meconium samples from 105 infants in a birth cohort study. After multivariable adjustment, delivery mode (p = 0.044), prenatal antibiotic use (p = 0.005) and peripartum antibiotic use (p < 0.001) were associated with beta diversity of the infant meconium microbiome. CS (vs. vaginal delivery) and peripartum antibiotics were also associated with greater alpha diversity of the meconium microbiome (Shannon and Simpson, p < 0.05). Meconium from infants born by CS (vs. vaginal delivery) had lower relative abundance of the genus Escherichia (p < 0.001). Prenatal antibiotic use and peripartum antibiotic use (both in the overall analytic sample and when restricting to vaginally delivered infants) were associated with differential abundance of several bacterial taxa in the meconium. Bacterial taxa in the meconium microbiome were also differentially associated with infant excess weight at 12 months of age, however, sample size was limited for this comparison. In conclusion, prenatal and peripartum antibiotic use along with CS delivery were associated with differences in the diversity and composition of the meconium microbiome. Whether or not these differences in the meconium microbiome portend risk for long-term health outcomes warrants further exploration.

We report a case of phthiriasis palpebrarum in an immunocompetent individual along with the review of the literature. A 61-year-old woman presented with a 2-month history of itching and burning sensation in both eyes. Examination revealed lice and nits anchored to the eyelashes with a mild follicular conjunctival reaction and no evidence of discharge. The patient recovered fully within 2 weeks after manual removal of the lice and crusts along with topical antibiotic ointment and oral ivermectin, with no evidence of lice or nits on follow-up. This study suggests that patients presenting with itching of the eyelids and other asthenopic symptoms should be carefully examined by slit-lamp examination, to not miss out on unusual diagnoses such as found in this case.

Aim: To study if there is an increase in the serum levels of Glial Fibrillary Acidic Protein (GFAP) in patients with glioblastoma so that it can be used as a diagnostic biomarker for these cases. Design: Prospective observational study. Material and Methods: We prospectively examined 193 patients, out of which 25 were controls (patients with degenerative spinal disease or CV junction anomaly), 79 were tumors other than glioma, 45 were histologically proven gliomas except glioblastoma and 44 were histologically proven glioblastomas. Serum was taken from the patients in the pre-operative period. Serum GFAP levels were determined using a biotin-labeled antibody-based sandwich enzyme immunoassay for the quantitative measurement of GFAP in ng/ml. Statistical Analysis: Data analysis was performed by using SPSS (Statistical Package for Social Sciences) version 20:0. Statistical significance was defined as P value < 0.05. Receiver operating characteristic (ROC) curve analysis was used to find the cut-off value of serum GFAP for glioblastoma patients. Results: In Group A (25 controls) and Group B (79 patients with non-glial brain tumors), no patient had detectable levels of GFAP in their serum. Out of the 45 patients with histologically proven gliomas except glioblastoma (Group C), 12 patients had raised serum GFAP levels. Out of the 44 patients with histologically proven glioblastomas (Group D), 38 patients had raised serum GFAP levels while in the remaining 6, the levels of serum GFAP were not detectable. The sensitivity of serum GFAP levels in diagnosing glioblastoma patients was 86.36% and the specificity was 91.95%. The diagnostic accuracy of the test was 90.67%. Conclusions: Serum GFAP is a sensitive and specific marker for glioblastoma and can be a useful pre-operative serum biochemical investigation in differentiating glioblastoma cases from other brain tumors.

With the advent of musculoskeletal ultrasound (US), there has been a paradigm shift in the way rheumatological conditions are detected, quantified and managed. Small joints of the wrist and hand play an important role in the diagnosis and characterization of inflammatory arthritis. Successful scanning of the wrist and hand requires good scanning equipment, thorough knowledge of anatomy and scanning protocols. The dorsal recesses of the wrist, metacarpophalangeal joint, proximal interphalangeal joint and the distal interphalangeal joint are scanned to look for joint effusion, synovial hypertrophy and cortical erosions. The extensor tendons of the wrist and hand have a synovial sheath at the level of the distal radius. The flexor tendons and the median nerve along the volar aspect of the wrist pass through a fibro-osseous tunnel known as the carpal tunnel. US pathologies commonly encountered in inflammatory arthritis have been very well defined in literature, so that there is better reproducibility of the tests and reduction in the inter-observer variation.

Knowledge of the anatomy of the shoulder and its periarticular soft tissues and scanning techniques are essential for successful ultrasound (US) examination of the shoulder. Inflammatory conditions or overuse injuries affecting the periarticular structures are the most common causes of nontraumatic shoulder pain. Dynamic imaging with US is an added advantage and scores over similar cross-sectional imaging modalities. In a routine US examination of the shoulder joint, the extraarticular segment of the long head of biceps, rotator-cuff tendons and their muscle bellies, rotator interval, subacromial-subdeltoid bursa, posterior joint recess, and the acromioclavicular joint are assessed systematically.

Accurate diagnosis and treatment planning are essential for obtaining ideal treatment result in cases involving mandibular incisor extraction. This case report describes a 15-year-old female with balanced soft-tissue profile, peg-shaped maxillary lateral incisors, and moderate mandibular anterior crowding treated with a mandibular incisor extraction. Ideal overbite and overjet were achieved. "Black triangle" formation was avoided due to the bodily movement of mandibular incisors and the use of uprighting springs for ideal axial inclination of mandibular incisors. A mandibular incisor extraction can be an effective treatment option in carefully selected clinical situations.

Tennis leg is caused by a rupture of the medial head of the gastrocnemius muscle, usually at its distal musculotendinous junction region. However, tears in this muscle and its tendon are also included under the term ′tennis leg′. It is seen regularly in practice and is an important cause of a painful calf. The common USG findings include: disruption of the pinnate pattern of the distal medial gastrocnemius, usually near the junction of the triceps surae (which is the echogenic line between the gastrocnemius, the soleus, and the plantaris muscles), fluid tracking along the fascia, adjacent hematoma, and intramuscular tears as well as hematomas. USG is useful for confirming the diagnosis, excluding other causes of a painful calf, for assessing the severity of the disease, and in follow-up.

Cerclage wiring may be used to optimize the stability of intramedullary nail or plate fixations in comminuted proximal femoral fractures, periprosthetic fractures, and other selected cases. In this article, we presented a novel case of iatrogenic sciatic nerve entrapment from cerclage wiring used to supplement intramedullary nail fixation. We also illustrate and highlight the role of ultrasound in assessing the sciatic nerve to make a timely diagnosis.

Summary:. Several studies have linked calcification of the thoracic and lower extremity arterial trunks to an increased risk of developing coronary artery disease (CAD). Calcifications of the radial and/or ulnar artery are regularly identified in hand/wrist x-rays; however, the clinical relevance of these findings as related to identifying subclinical CAD is not well understood. Associations between CAD and upper extremity calcifications have been reported, but the timeline is unclear. The purpose of this study was to evaluate the association between upper extremity arterial calcifications on hand radiographs with CAD by coronary artery calcification (CAC) scoring in patients with no known history of CAD. This is a pilot single-center, prospective, matched cohort study. We included patients with no known history of CAD, related symptoms, or major risk factors. We recruited five patients with calcifications (cal+) and five patients matched by age, race, sex, and medical history but without calcifications (cal−). CAC scores were determined from computed tomography scanning, and lipid profile was evaluated. In the cal+ group, the mean CAC total score was 244.1; in the control (cal−) group, it was 85.2. The mean total cholesterol levels were 220.8 mg per dL and 167 mg per dL in the cal+ and cal− groups, respectively. Two cal+ patients with CAC scores of 937 and 669 died shortly after being enrolled in our study. Preliminary findings suggest that calcifications in the radial or ulnar artery in otherwise asymptomatic patients with no history of CAD may be an independent sign of CAD.

Due to very less bioavailability (20%) of Rosuvastatin calcium, an attempt was made to develop and optimize microemulsion formulation. Capmul MCM, Tween 20 and PEG 400 were selected as oil, surfactant and cosurfactant respectively as the drug is having higher solubility in them. 3:1% w/w S:CoS was selected as it gave higher microemulsion area. Optimized batch (ME-1) was selected having 5% Capmul MCM, 50% Tween 20:PEG 400 and 45% water based on evaluation parameters globule size, zeta potential, PDI, % transmittance. [ABSTRACT FROM AUTHOR]

PURPOSE: Chronic graft-versus-host disease (cGVHD) is a significant cause of morbidity and mortality among patients after allogeneic hematopoietic stem cell transplant (HCT). The objective of our study was to determine if early assessment of matrix metalloproteinase-9 (MMP-9) and dry eye (DE) symptoms (via the DE Questionnaire-5 [DEQ-5]) had prognostic utility for the development of cGVHD and/or severe DE symptoms after HCT. MATERIALS AND METHODS: This was a retrospective study of 25 individuals who underwent HCT and had MMP-9 (InflammaDry) and DEQ-5 performed on day 100 post-HCT (D + 100). Patients also completed the DEQ-5 at 6, 9, and 12 months post-HCT. The development of cGVHD was determined by chart review. RESULTS: Overall, 28% of patients developed cGVHD over a median follow-up of 229 days. At D + 100, 32% of patients had a positive MMP-9 in at least one eye and 20% had a DEQ-5 ≥6. However, neither the presence of a positive MMP-9 nor a DEQ-5 score ≥6 at D + 100 predicted the development of cGVHD (MMP-9: hazard ratio [HR]: 1.53, 95% confidence interval [CI]: 0.34-6.85, P = 0.58; DEQ-5 ≥6: HR: 1.00, 95% CI: 0.12-8.32, P = 1.00). In addition, neither of these measures predicted the development of severe DE symptoms (DEQ-5 ≥12) over time (MMP-9: HR: 1.77, 95% CI: 0.24-12.89, P = 0.58; DEQ-5 >6: HR: 0.03, 95% CI: 0.00-889.93, P = 0.49). CONCLUSION: Within our small cohort, DEQ-5 and MMP-9 assessment at D + 100 did not predict the development of cGVHD or severe DE symptoms.

Venetoclax is an approved treatment for relapsed/refractory Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN). We report a unique case of venetoclax monotherapy used for front-line induction and as a bridge to allogeneic hematopoietic stem cell transplantation (HCT). Venetoclax therapy resulted in rapid complete resolution of skin lesions, however, treatment interruption due to neutropenia led to brisk cancer recurrence. Fortunately, the patient responded to re-challenge and was able to undergo HCT. Venetoclax is active in the first-line treatment setting for BPDCN, however its effect on blood counts and durability of response should be further studied.

Acute macular neuroretinopathy (AMN) is a deep retinal ischemic manifestation. It has been reported after the use of sympathomimetics, childbirth, bee sting, oral contraceptives, flu-like illness, intravenous contrast agents and bodily trauma not directly involving the eyes. We report a case of AMN following blunt ocular trauma. An 18-year-old male presented with an acute history of blurring of vision following blunt trauma to the right eye. Spectral domain optical coherence tomography (SD-OCT) showed hyperreflectivity of the outer nuclear layer with ellipsoid layer disruption. This report highlights AMN as a manifestation of blunt trauma, presence of which may be an indicator of poor visual prognosis.

Several case reports regarding complications of ventriculoperitoneal (VP) shunt have been published, but peroral extrusion of shunt tube is unusual and reported less frequently. A 4-year-old male child with previous history of VP shunt insertion for congenital hydrocephalus along with shunt revisions twice presented with peritoneal end of shunt tube protruding through the mouth following an acute episode of vomiting. He was conscious without any signs of infection or neurologic deficits. The distal portion of the tube was removed uneventfully with the help of upper GI endoscope that, in addition to removal, provided better views for the identification of site and size of perforation. Peroral extrusion of the shunt tube needs immediate treatment that includes removal of extruded shunt tube, treatment of underlying infection, and attention to perforated viscus. We review the possible pathogenesis of this entity and various treatment options.

Colloid cysts are benign cystic lesions characteristically arising from the third ventricle roof close to the foramen of Monro. Although incredibly rare, hemorrhage within a third ventricular colloid cyst is sparsely reported. To the best of our knowledge, no cases of hemorrhage within the fourth ventricle colloid have ever been documented. Here, we present an interesting case describing a hemorrhagic colloid cyst situated within the fourth ventricle of a 55-year-old female patient who presented with symptoms of headache, vomiting, and gait imbalance. The cyst was excised during surgery via a suboccipital microscopic telovelar approach. Our findings led us to the conclusion that, despite being extremely rare, colloid cysts in the fourth ventricle can present with hemorrhagic episodes, which can exacerbate symptoms and hasten neurological decline. As a result, the presence of unusual radiological characteristics in a fourth ventricle lesion should prompt medical practitioners to suspect an atypical colloid cyst. This consideration can be pivotal in making informed surgical decisions. Expedited management and a microsurgical approach are recommended strategies for a better outcome.