Total upper and lower eyelid reconstruction using deltopectoral flap

Total upper and lower eyelid unilateral full thickness reconstruction is a surgical challenge. A case of right orbital haemangioma with unilateral complete defect of total upper and lower eyelids with right orbital exenteration is reported, together with the surgical technique of reconstruction. Patient was a 24-year-old female who underwent right orbital exenteration with total upper and lower eyelid excision for orbital haemangioma presented after 3 weeks of the above procedure. In the first stage split thickness skin grafting is used to resurface orbital cavity raw area followed by staged reconstruction of total upper and lower eyelid reconstruction using pedicle deltopectoral flap. This reconstruction provided stable eyelid reconstruction to retain ocular prosthesis with concealed and minimal donor area. After reconstruction patient underwent rehabilitation with ocular prosthesis, now the patient is satisfied with cosmetically acceptable results.KEY WORDS: Deltopectoral flap, total eyelid reconstruction, total upper and lower eyelid reconstruction with DP flap     

Three-dimensional echocardiography in congenital heart disease

Complex intracardiac anatomy and spatial relationships are inherent to congenital heart defects (CHDs). Recognition of the limitations of two-dimensional echocardiography has stimulated clinical interest in three-dimensional imaging. The current review examines contemporary studies in the following areas where three-dimensional echocardiography has provided additive value in CHD: (1) visualization of morphology, (2) quantitation of chamber sizes and ventricular function, and (3) image-guided interventions.     

Comparable efficacy of standardized Ayurveda formulation and hydroxychloroquine sulfate (HCQS) in the treatment of rheumatoid arthritis (RA): a randomized investigator-blind controlled study

Hydroxychloroquine sulfate (HCQS) is a popular disease-modifying antirheumatic drug (DMARD) despite modest efficacy and toxicity. Ayurveda (ancient India medicinal system) physicians treat rheumatoid arthritis (RA) with allegedly safer herbal formulations. We report a head-to-head comparison in an exploratory drug trial. The objective is to compare standardized Ayurvedic formulations and HCQS in the treatment of RA. One hundred twenty-one patients with active moderately severe RA (ACR 1988 classified) were randomized into a 24-week investigator-blind, parallel efficacy, three-arm (two Ayurvedic and HCQS) multicenter drug trial study; polyherb (Tinospora cordifolia and Zingiber officinale based) and monoherb (Semecarpus anacardium). Study measures included joint counts (pain/tenderness and swelling), pain visual analogue scale, global disease assessments, and health assessment questionnaire. Oral meloxicam (fixed-dosage schedule) was prescribed to all patients during the initial 16 weeks. Patients on prednisolone could continue a fixed stable dose (<7.5 mg daily). Rescue oral use of paracetamol was permitted and monitored. All groups matched well at baseline. An intent-to-treat analysis (ANOVA, significance P < 0.05) did not show significant differences by treatment groups. In the polyherb, monoherb, and HCQS arms, 44%, 36%, and 51%, respectively, showed ACR 20 index improvement. Several efficacy measures improved significantly in the HCQS and polyherb groups with no difference between the groups (corrected P). However, the latter was individually superior to monoherb. Only mild adverse events (gut and skin, and none withdrew) were reported with no differences between the groups. Forty-two patients dropped out. This preliminary drug trial controlled for HCQS demonstrated a standardized Ayurvedic polyherb drug to be effective and safe in controlling active RA. A better-designed study with a longer evaluation period is recommended.     

Neonatal Hearing Screening Programme (NHSP): At A Rural Based Tertiary Care Centre

Deafness is the most common curable childhood handicap. It is a well recognised fact that unidentified hearing impairment can adversely affect optimal speech and language development and therefore academic, social and emotional development. Universal neonatal hearing screening programmes are implemented in many developed countries. However it is still in its early stage in India. The incidence of hearing impairment in India is 1–6 per thousand newborns screened (Paediatrics 19:155–165, 1998; Indian J Paediatr 74(6):545–549, 2007; Status of Disability in India, pp 172–185 2000). To determine the incidence of permanent hearing loss of moderate to evere variety in neonates taking care in a tertiary care rural based hospital in Gujarat. It was a non randomised observational study done for duration of 3 years. All neonates born in Shri Krishna Hospital underwent screening using two stage protocols with DPOAE test and final confirmation done with BERA. Total 2534 neonates were screened out of them 52 failed and 2482 (97.94 %) neonates passed in the 1st DPOAE test with 2.05 % refer rate. Total 7 (2 per 1000) neonates were detected with hearing impairment. 10 % neonates had one or other high risk factor. Out of high risk neonates, 1.8 % were diagnosed with hearing impairment in high risk group. Overall the follow-up rate was 72.7 %. Hospital based universal hearing screening of new born before discharge is feasible at a rural based tertiary care centre. Non specialist staff is invaluable in achieving a satisfactory referral rate with two stage hearing screening protocol. However, more efficacious tracking and follow up system is needed to improve the follow up rate for diagnosis.     

Obesity Is Associated with Risk of Progression for Low-risk Prostate Cancers Managed Expectantly

Background

Active surveillance (AS) is an expectant management strategy for prostate cancer (PCa). The impact of obesity on progression is not well characterized in this population.

Objective

To determine if obesity is associated with progression in men on AS for low-risk PCa.

Design, setting, and participants

Men undergoing AS for low-risk PCa (no Gleason pattern ≥4, three or fewer cores involved or one-third or less of the total number of cores involved, and no core with >50% cancer involvement) were identified at our institution.

Outcome measurements and statistical analysis

The outcomes were pathologic progression (defined as no longer meeting low-risk criteria on follow-up biopsy) and therapeutic progression (defined as intent to initiate active treatment). Kaplan-Meier curves and multivariable logistic regression and Cox proportional hazards models were used, with separate models for reclassification at confirmatory biopsy (first biopsy after diagnostic biopsy) and progression beyond confirmatory biopsy.

Results and limitations

In this cohort of 565 men (median follow-up: 48 mo), 124 (22%) were obese (body mass index [BMI] ≥30 kg/m²). Pathologic and therapeutic progression occurred in 168 men (30%) and 172 men (30%), respectively. No association was noted between obesity and risk of progression at the confirmatory biopsy. However, beyond confirmatory biopsy, obesity was associated with a greater probability of pathologic progression (p = 0.007) and therapeutic progression (p = 0.007) in Kaplan-Meier analyses. In adjusted Cox models, each 5-unit increase in BMI was associated with an increased risk of pathologic progression (hazard ratio [HR]: 1.5; 95% confidence interval [CI], 1.1–2.1; p = 0.02) and therapeutic progression (HR: 1.4; 95% CI, 1.0–1.9; p = 0.05). The main limitation is the retrospective design, limiting the ability to assess BMI changes over time.

Conclusions

Obesity was associated with a significantly increased risk of progression beyond the confirmatory biopsy. This suggests an increased risk of long-term biologic progression rather than solely misclassification.

Patient summary

As opposed to immediate active treatment (surgery or radiation), active surveillance (AS) involves closely monitoring low-risk prostate cancers and only using active treatment if there are signs of progression. Our study is the first to suggest that obesity is associated with a higher risk of cancer progression while on AS. Further research is needed to determine if diet and exercise can decrease the risk of cancer progression while on AS.     

Portal Venous Thrombosis After Distal Pancreatectomy: Clinical Outcomes

Aim

Outcomes of patients developing portal vein (PV) thrombosis (PVT) after distal pancreatectomy (DP) are unknown. The goal of this study was to identify risk factors for PVT and describe the long-term outcomes in these patients.

Methods

Patients undergoing DP without repair or reconstruction of the PV between 2001 and 2011 were included. Patients that showed evidence of PVT on pre-operative imaging were excluded from the study. Location and extent of thrombosis was determined by post-operative computed tomography or ultrasound imaging in all patients. Evidence of systemic thrombosis (if present) in addition to PVT was also documented.

Results

In the study period, 991 patients underwent DP and 21 (2.1 %) patients were diagnosed with PVT. Pancreatic neoplasm was the most frequent indication for operation (n?=?11). Thrombus occurred in the main PV in 15 and the right branch of the PV in 8 patients. Complete PV occlusion occurred in nine patients with a median time to diagnosis of 16 days (range 5–85 days). Seventeen patients were anticoagulated for a median duration of 6 months (range 3.3–36 months) after the diagnosis of PVT. Over a median follow-up of 22 months, resolution of PVT occurred in seven patients. Predictors of non-resolution of PVT included anesthesia time >180 min (p?=?0.025), DM type II (p?=?0.03), BMI?>30 Kg/m² (p?=?0.03), occlusive PVT (p?<?0.001), or thrombus in a sectoral branch (p?=?0.02). Anticoagulation therapy did not influence the frequency of thrombus resolution and was complicated by gastrointestinal hemorrhage in four patients. There was no mortality as a direct result of PVT or anticoagulation.

Conclusion

PVT after distal pancreatectomy is a rare complication. Serious complications as a direct result of PVT in this setting are uncommon and are not dependent on thrombus resolution. Although anticoagulation does not appear to influence the rate of PVT resolution in this small retrospective series, we support the use of anticoagulation until larger, controlled studies define clear advantages or disadvantages.     

Concomitant systemic lupus erythematosus and HIV: Case series and literature review

Objectives

To determine the effect of systemic lupus erythematosus (SLE) and human immunodeficiency virus (HIV) infection on the course of each other and to review the published reports on concomitant SLE and HIV infection.

Methods

We performed a retrospective review of the records of patients with SLE and HIV seen in the Department of Rheumatology at the Inkosi Albert Luthuli Central Hospital, Durban, South Africa. We used the terms “systemic lupus erythematosus” and “HIV” or “AIDS” to identify patients with SLE and HIV infection reported in the English medical literature.

Results

We identified 13 patients with SLE and HIV infection. All the patients were females and there were 11 African blacks and 2 Indians. SLE and HIV infection were diagnosed together in 6 patients. In this group, there were 5 lupus flares in 4 patients, and 2 of the flares followed highly active anti-retroviral treatment (HAART). Five patients developed HIV after the diagnosis of SLE. The 3 patients in whom follow-up data was available had inactive SLE, one of whom was on HAART. Two HIV-positive patients developed SLE after receiving HAART for 30 and 35 mo. Seven of our patients also had tuberculosis. Our literature search identified 58 previously reported patients with HIV and SLE.

Conclusion

Our case series and review of the literature show that there is a reduction in SLE disease activity in patients with concomitant SLE and HIV. However, when lupus flares occur in HIV-positive patients, they are unrelated to the use of HAART.     

Evaluation of Effectiveness of Integrated Intervention in Autistic Children

Objectives

To assess the effectiveness of integrated therapy over the past 3 y on the recipient autistic children and its correlation with the following variables - age at admission, duration of therapy given and initial severity of symptoms.

Methods

The index study was a retrospective study with 18 autistic children as subjects; the maximum duration of intervention was 3 y. The integrated approach consisted of special education using principles of applied behavior analysis, occupational and speech therapy. The progress records, the occupational therapy and the speech therapy progress reports were tabulated as data. The Childhood Autism Rating Scale (Schopler, Reichler and Renner, 1986) was used for evaluation of severity of symptoms at admission and in present day. The data was then compared and analyzed.

Results

The present study showed significant positive results. Only few domains requiring very high integrated cognitive and sensorimotor functioning showed non-significant results. Age at intervention correlated negatively and, duration of therapy given and initial severity of symptoms correlated positively with effectiveness of therapy.

Conclusions

Continuous feedback and modification of the therapy is required to maintain performance and develop target interventions for problematic areas identified. Longitudinal as well as comparative studies are required to better understand the benefits of integrated approach.