Dermatology

Assessment of melanogenesis in a pigmented human tissue-cultured skin equivalent Nadja Nicole Zoller, Matthias Hofmann, Manuel Butting, Igor Hrgovic, Jürgen Bereiter-Hahn, August Bernd, Roland Kaufmann, Stefan Kippenberger, Eva Valesky Indian Journal of Dermatology 2019 64(2):85-89 Background: Organotypic tissue-cultured skin equivalents are used for a broad range of applications either as possible substitute for animal tests or for transplantation in patient-centered care. Aims: In this study, we implemented melanocytes in a tissue-cultured full-thickness skin equivalent, consisting of epidermis and dermis. The versatility of this skin-like model with respect to pigmentation and morphological criteria was tested. Materials and Methods: Pigmented skin equivalents were morphologically characterized, and melanogenesis was evaluated after treatment with kojic acid – a tyrosinase inhibitor and forskolin – a well-known activator of the cyclic adenosine 3,5-monophosphate pathway. Pigmentation was measured either by determination of the extinction at 400 nm after melanin extraction with KOH correlated to a melanin standard curve or by reflectance colorimetric analysis, monitoring reflectance of 660 nm and 880 nm emitting diodes. Results: The morphological analysis revealed characteristic epidermal stratification with melanocytes located at the basal layer. Stimulation with forskolin increased the pigmentation, whereas treatment with kojic acid caused bleaching. Conclusion: The present study demonstrates that the herein-introduced organotypic tissue-cultured skin equivalent is comparable to the normal human skin and its versatility in tests regarding skin pigmentation. Therefore, this model might help understand diseases with dysfunctional pigmentation such as melasma, vitiligo, and postinflammatory hyperpigmentation.

Biophysical measurements and ultrasonographic findings in chronic dermatitis in comparison with uninvolved skin Taraneh Yazdanparast, Kamran Yazdani, Philippe Humbert, Alireza Khatami, Saman Ahmad Nasrollahi, Leila Izadi Firouzabadi, Alireza Firooz Indian Journal of Dermatology 2019 64(2):90-96 Background: Nowadays noninvasive techniques are performed to evaluate the biophysical properties of skin in vivo. Aims: The aim of this study was to evaluate the biophysical and ultrasonographic properties of skin in chronic contact or atopic dermatitis to provide better insight into pathogenesis, diagnosis, and treatment response. Materials and Methods: The stratum corneum hydration, transepidermal water loss (TEWL), pH, erythema, melanin, sebum, friction, temperature, elasticity parameters (R0, R2, and R5), the thickness and echo-density of epidermis, dermis, and subepidermal low-echogenic band (SLEB) were measured on lesional, perilesional, and symmetrical skin of 22 chronic dermatitis patients. The average of perilesional and symmetrical skin values (control) was compared with lesional values. Results: Stratum corneum hydration (P<0.001), friction (P=0.02), sebum (P=0.01), and R0 (P<0.001) were significantly lower in lesion, TEWL (P=0.03), pH (P=0.001), erythema (P=0.004), and temperature (P=0.04) were significantly higher in lesion. The thickness of epidermis (P=0.002), dermis (P=0.034), and SLEB (P<0.001) were significantly higher in lesion; and the echo-density of dermis (P<0.001) and SLEB (P<0.001) was significantly lower in lesion. Conclusion: Chronic contact and atopic dermatitis are characterized by certain changes in biophysical and biomechanical properties of the skin. The evaluation of these parameters might be useful in the early diagnosis and assessment of treatment response.

Systemic redox imbalance along with increased serum sialic acid is prevalent in patients with active vitiligo: A study from a tertiary care teaching hospital of Eastern India Nilotpal Banerjee, Sanchaita Gayen, Dolanchampa Modak, Somenath Sarkar, Bibhuti Saha, Sumi Mukhopadhyay Indian Journal of Dermatology 2019 64(2):97-100 Background: Vitiligo is one of the common depigmenting disorders causing disfigurement and affecting the quality of life. Redox imbalance is known to play a contributory role in melanocyte destruction. Serum sialic acid (SA) is an important marker of the acute-phase response and is associated with oxidative protein damage. Aim: The aim of this study was to analyze the status of oxidative stress markers and serum SA in vitiligo patients and to correlate the same with disease activity. Materials and Methods: The different oxidative stress parameters namely superoxide dismutase (SOD), malondialdehyde (MDA), and serum SA were measured spectrophotometrically using standard biochemical methodologies in all the study subjects. Results: Serum SOD and MDA values were higher in patients with active vitiligo (n = 23) as compared to stable vitiligo (n = 20) and healthy controls (n = 20). The MDA/SOD ratio was higher in patients with active vitiligo (P<0.0001). Serum SA was increased in active vitiligo as compared to stable vitiligo and healthy controls (P<0.0001). Conclusion: This study indicates that patients with active vitiligo demonstrate enhanced MDA/SOD ratio and increased serum SA. The studied parameters can serve as an important tool to monitor disease activity in vitiligo.

A clinicopathological and immunofluorescence study of intraepidermal immunobullous diseases Keya Basu, Moumita Chatterjee, Abhishek De, Moumita Sengupta, Chhanda Datta, Pradip Mitra Indian Journal of Dermatology 2019 64(2):101-105 Context: Autoimmune blistering diseases (AIBDs) are characterized by autoantibodies directed against antigens of skin. Direct immunofluorescence (DIF) study helps in confirming the diagnosis where histopathology alone is noncontributory. Aims: This study aimed to evaluate the clinicopathological and DIF features of intraepidermal AIBD and to assess their relative diagnostic significance. Materials and Methods: It was an institution-based observational study. A total of 34 patients were studied over a period of 1½ years in the Department of Pathology in collaboration with the Department of Dermatology of a tertiary care hospital. The clinical, pathological, and DIF features were evaluated and documented. Statistical Analysis: Data were analyzed by statistical tests using GraphPad InStat. Results: Pemphigus vulgaris (PV) was the predominant type with 18 (53%) cases followed by 15 (44%) cases of pemphigus foliaceus (PF) and a single case of pemphigus erythematosus (PE). The age of the patients ranged from 17 to 85 years. Overall, there was a female preponderance in the study group. The most common presenting feature was pruritus (58.82%). Tzanck smear showed the presence of acantholytic cells in thirty (88.24%) patients. Characteristic histopathological features were present in all the cases of PV and PF except one case of PF which was found to be a case of PE. DIF study showed intraepidermal deposition of intercellular immunoglobulin G (IgG) and C3 both in PV and PF. The case of PE showed epidermal “antinuclear antibody” staining with IgG. Conclusion: Immunofluorescence study may be used as an additional tool for confirmation of diagnosis where histopathology alone is inconclusive.

Clinico-epidemiological study of disability due to leprosy at the time of diagnosis among patients attending a tertiary care institution Vengarakath Puthiyapura Reyila, Ambookken Betsy, Najeeba Riyaz, Sarita Sasidharanpillai, Pentam Veil Beegum Sherjeena, Maniparambath P Majitha, Deepa Mary Joseph Indian Journal of Dermatology 2019 64(2):106-111 Background: With the declared elimination of leprosy as a public health problem, the World Health Organization has shifted the focus on the disabilities and deformities associated with leprosy. Aims: The aim was to study the Grade 1 and Grade 2 disability among newly diagnosed leprosy patients. Materials and Methods: All newly diagnosed leprosy patients attending the Outpatient Department of Government Medical College, Kozhikode, from January 1, 2013 to December 31, 2013 were included in the study and the Grade 1 and Grade 2 disabilities observed were analyzed. Results: During the 1-year period, 76 patients were diagnosed to have leprosy. Grade 1 and Grade 2 disabilities were noted in 31.6% and 17.1%, respectively. Major factors identified as risk for leprosy disability at the time of diagnosis were age >45 years, >5 skin lesions, ≥2 thickened peripheral nerve trunks, pure neuritic and borderline tuberculoid spectra of leprosy. Limitation: As the study was conducted in a tertiary care center, it does not perfectly indicate the status in the community. Conclusion: Disability noted in nearly 50% of leprosy cases at the time of diagnosis highlights the need to improve the effectivity of existing health-care system in early case detection and timely referral. In addition, it underscores the need to educate the affected regarding protective eye, foot, and hand care, so that progression to Grade 2 disability can be prevented.

Awareness of family physicians towards antihistamines Sumaya Zeerak, Kiran Godse, Sujit Kumar Indian Journal of Dermatology 2019 64(2):112-114 Background: Antihistamines are one of the commonly prescribed groups of drugs for allergic disorders and pruritus. They are broadly grouped into two generations, the second-generation ones being more effective and with less side effects. The family physicians frequently use antihistamines as patients contact them initially for their problem. It will be interesting to know the mode of selection of antihistamines by them. Materials and Methods: The study was carried out on a sample of 100 family physicians. Primary data were collected from them after taking informed consent. A pre-validated questionnaire regarding knowledge, awareness, and prescribing schedule of antihistamines was filled up. The data were then analyzed with suitable statistical tests. Results: Almost 73% of physicians prescribed second-generation antihistamines, while 27% prescribed the first-generation ones. Only 15% of them were aware about the ARIA and GA2LEN guidelines and their recommendations for prescribing second-generation antihistamines over the older first-generation antihistamines, while 85% had not heard about them previously. A minimum 7% of practitioners revealed that they updosed the same drug four times in the treatment of urticaria, while 93% did not do it. Conclusion: Even though a sizeable percentage of family physicians prescribed second-generation antihistamines, most of them were not aware of their dosing guidelines.

Effectiveness and safety of metformin versus Canthex™ in patients with acanthosis Nigricans: A randomized, double-blind controlled trial Arindam Sett, Samiksha Pradhan, Karan Sancheti, Dibyendu Basu, Adrija Datta, Lekha Biswas, Sayan Das, Subhasis Kumar Pal, Nidhi Gupta, Amrita Sil, Nilay Kanti Das Indian Journal of Dermatology 2019 64(2):115-121 Background: Acanthosis nigricans has been associated with conditions of insulin resistance such as obesity, polycystic ovary syndrome, and type 2 diabetes. Metformin and alpha-lipoic acid, two types of insulin-sensitizing agents, have been demonstrated to reduce insulin levels and improve insulin sensitivity. Alpha-lipoic acid is available as a fixed-dose combination with biotin, calcium pantothenate, and zinc sulfate as Canthex™. Aims: This study aimed to compare the effectiveness, safety, and improvement of the insulin resistance profile of Canthex™ and metformin in acanthosis nigricans. Materials and Methods: In this double-blind, randomized (1:1), active-controlled trial (CTRI/2017/02/007880), participants received either metformin 500 mg BD or Canthex™ BD for 12 weeks. Effectiveness parameters were improvement of severity of neck lesions and neck texture. Serum fasting insulin level, glucose, lipids, body weight, waist circumference, body mass index (BMI), and homeostatic model assessment-insulin resistance (HOMA-IR) were also assessed at baseline and at the end of the study. Adverse effects and changes in routine laboratory parameters were taken as safety parameters. Results: Thirty-three patients were analyzed by modified-intention-to-treat criteria. Severity of neck lesions and texture were comparable at baseline and it showed significant reduction (P<0.001) in both the treatment arms from the first follow-up onward. No intergroup variation was observed in any of the follow-ups. There was reduction in the values of fasting insulin, blood sugar, total cholesterol, and thyroid-stimulating hormone in both the groups. Weight, BMI, and waist circumference and BMI reduced significantly in both the groups. HOMA-IR decreased significantly in metformin group (P<0.001). Conclusion: Canthex™ is as effective and safe as metformin in the management of acanthosis nigricans and associated features of insulin resistance.

Mucocutaneous adverse reactions of cancer chemotherapy and chemoradiation Sheikh Naveed, Devinder Mohan Thappa, Biswajit Dubashi, Jagadeesan Pandjatcharam, Malathi Munisamy, Nidhi Singh Indian Journal of Dermatology 2019 64(2):122-128 Background: With the introduction of newer anti-cancer agents, the adverse effects have become more rampant which call for concern in the treatment of patients with cancer. Hence, the assessment and management of dermatological adverse effects of anti-cancer therapy have become a significant part of the care of patients with cancer and require proper and close collaboration between the dermatologists and the oncologists. Aims: To assess the frequency and pattern of mucocutaneous adverse reactions to cancer chemotherapy and chemoradiation and grade them according to their severity and to identify hematological and biochemical changes related to cancer chemotherapy-induced mucocutaneous adverse reactions. Materials and Methods: This was a descriptive study done among 226 patients in an Indian tertiary care hospital, who presented with mucocutaneous adverse reactions to either chemotherapy alone or combination of chemotherapy and radiation to dermatology, medical oncology and radiotherapy outpatient departments. Detailed history and examination were undertaken. Visual analog score (VAS) was employed to quantify pain and pruritus. Correlation of various biochemical and hematological parameters with chemotherapy-induced adverse reactions was attempted and grading of adverse reactions was done based on the severity scale of Common Terminology Criteria for Adverse Events (CTCAE). Results: The common cutaneous adverse reactions observed in our study were nail changes (194 patients; 85.84%), followed by skin changes (191; 84.51%), hair changes (159, 70.35%), mucosal changes (34, 15.04%), and other miscellaneous manifestations. Grade 1 manifestations comprised of 49.91% of total manifestations followed by Grade 2 (45.45%) and Grade 3 (5.64%). In addition to bleomycin, other chemotherapeutic agents also had been shown to produce flagellate dermatitis in our study. Conclusion: Nail changes, skin changes, hair changes and mucosal changes occurred frequently as a significant side effect of chemotherapy, which a physician should be aware of, while selecting a chemotherapeutic drug.

Combination of hydroquinone and fractional CO2 laser versus hydroquinone monotherapy in melasma treatment: A randomized, single-blinded, split-face clinical trial Sanaz Nourmohammadi Abadchi, Farahnaz Fatemi Naeini, Elham Beheshtian Indian Journal of Dermatology 2019 64(2):129-135 Background: Melasma is a chronic hyperpigmentation skin disorder mainly affecting women in the reproductive age. Available treatments for melasma do not lead to long-term satisfactory results. Aims: This study aimed to compare the efficacy of fractional CO2 laser in combination with topical therapy to topical therapy alone. Materials and Methods: Forty women with bilateral melasma were studied in this randomized single-blinded clinical trial. Each side of the face was randomly allotted to either topical hydroquinone 4% or combination of topical hydroquinone 4% and fractional CO2 laser. Patients received three sessions of laser therapy at 3-week intervals. Hydroquinone 4% application on both sides maintained for 3 months after the last laser session. The clinical improvement (darkness [D] and homogeneity [H] of hyperpigmentation) was measured by a blinded main investigator and an outcome assessor. Furthermore, improvement was assessed by physician's global assessment (PGA) and patient satisfaction (visual analog scale [VAS] score). Results: Significant reduction in D observed 3 weeks after combination therapy (P<0.001) and 6 weeks after monotherapy (P<0.001). Reduction in H became significant after 6 weeks in both groups (P<0.001). However, the two methods were not considerably different in any session (P>0.05). Furthermore, control and experiment sides were not significantly different considering VAS score and PGA (P>0.05). Conclusion: Considering the short-term outcome of laser and hydroquinone therapy, we can apply it to obtain earlier positive results. However, because of the lack of significant difference between the two methods and also the high cost of laser therapy, it seems better not to recommend fractional CO2 laser to patients as adjunctive therapy for long-term treatment of melasma.

Summer-associated dermatitis: A cross-sectional study of a unique eczematous dermatosis in South India Gurumoorthy Rajesh, Mohamed Rafeek, Kaliaperumal Karthikeyan Indian Journal of Dermatology 2019 64(2):136-142 Background: In our hospital setup located in the tropical zone, during each summer, we frequently come across a unique eczematous dermatosis among elderly females that typically occur in summer. Aims and Objectives: We carried out this study with the objective of studying the demographic and clinical features of this dermatosis. Materials and Methods: In this hospital-based descriptive study, we enrolled twenty consecutive patients presenting with typical features of the dermatosis of interest, such as itchy eczematous scaly papule and plaques distributed predominantly over flexures, self-limiting in nature, and with summer exacerbation. Detailed history, clinical examination, and laboratory investigations were carried out. Results: All were females with a mean age of 52.35±15.74 years. Mean age at onset of the disease was 50.80±15.77 years. The onset and exacerbation of lesions typically occurred during summer. The mean duration of the disease was 17.75±15.80 months. The typical lesions were multiple well-defined erythematous scaly papules and plaques bilaterally symmetrically distributed predominantly over the flexures. All biopsies showed spongiotic dermatitis picture and direct immunofluorescence was negative in all of them. Conclusion: This unique dermatosis which occurs in elderly females has not been widely reported. With clinical features and results of various investigations, it would be appropriate to call it “summer-associated dermatitis.”

Medical Sciences

Personalized Medicine OP Gupta Journal of Mahatma Gandhi Institute of Medical Sciences 2019 24(1):1-3

Coventional insulin versus insulin analogs Anil Gomber, Apoorva Gomber Journal of Mahatma Gandhi Institute of Medical Sciences 2019 24(1):4-6

Atopic March Dipti Jain Journal of Mahatma Gandhi Institute of Medical Sciences 2019 24(1):7-8

Sports physiology – An upcoming avenue Ruchi Kothari, Snigdha Sharma Journal of Mahatma Gandhi Institute of Medical Sciences 2019 24(1):9-12 The physiology of sports embodies a wide and diverse range of scientific interests. It is a recent outlet emanating from the discipline of exercise physiology that encompasses application of the concepts of exercise physiology to training athletes and enhancing sports performance. Sports physiology, a field that was once pursued almost exclusively in research laboratories and cardiac rehabilitation programs, is now commonly applied in comprehensive sports medicine clinics. Cardiorespiratory fitness is one of the most important parameters of physical fitness of an individual. This can be evaluated by assessing aerobic capacity (VO2max) and heart rate variability indices signifying the cardiac autonomic sympathovagal regulation. Both of these parameters derived from cardiorespiratory fitness assessment have been found sensitive to training effects in team sports players, thus of relevance in sports physiology.

The persisting environmental problem of disposal of expired and unused medicines Abin Mani, Vijay Thawani Journal of Mahatma Gandhi Institute of Medical Sciences 2019 24(1):13-16 India continues to have the persisting environmental problem of disposal of expired, unused, unwanted medicines. Since this has not been studied well, the exact repercussions, therefore, are not hitherto known fully. There are no laws in country worthy of handling this problem. The municipal corporations handling the waste have not been sensitized to it. The media are insensitive to it, and populations are disorganized to take up the issue. Hence, the environment continues to suffer and will end with higher complication of human life and environment.

The national strategic plan for tuberculosis step toward ending tuberculosis by 2025 Sunil D Khaparde Journal of Mahatma Gandhi Institute of Medical Sciences 2019 24(1):17-18

Prevalence and antibiotic resistance pattern of Metallo-β-lactamase-producing Pseudomonas aeruginosa isolates from clinical specimens in a tertiary care hospital Vinita Choudhary, Nita Pal, Saroj Hooja Journal of Mahatma Gandhi Institute of Medical Sciences 2019 24(1):19-22 Background: Pseudomonas aeruginosa is emerging as a nosocomial pathogen by producing metallo-β-lactamases (MBLs) and acquiring resistance to many antimicrobial agents. The infections caused by metallo-beta-lactamases producing P. aeruginosa (MBL-PA) are associated with higher rates of mortality, morbidity, and overall healthcare costs. Aim: The aim of the study was to find the incidence of MBL in P. aeruginosa isolates and their antimicrobial resistance pattern. Material and Methods: A total of 180 non-duplicate P. aeruginosa isolates from various clinical specimens between April 2016 and March 2017 were subjected to susceptibility testing by disc diffusion test as per the Clinical and Laboratory Standards Institute guidelines 2015. Imipenem and meropenem resistant isolates were selected for the detection of MBL production by disc potentiation test and modified Hodge test. Results: Out of 180 isolates of P. aeruginosa, MBL was detected in 36 (20.00%) isolates. Resistance was significantly higher in the MBL-PA with 94.44% resistance to aztreonam followed by cefoxitin (91.66%), piperacilline/tazobactam and cefepime (80.55%). The prevalence of multidrug-resistant and possible extensively drug-resistant isolates was significantly higher among the MBL group as compared to that in the non-MBL group [50.00% vs. 11.11% and 5.55% vs. 0.69% (P = <0.05)]. None of the isolates were pan drug resistant. Conclusions: Increasing prevalence of MBL-PA producing isolates in hospital settings makes it important to perform routine detection of MBL strains for the purpose of infection control and for minimizing the adverse outcome of infection.

Prospective evaluation of the diagnostic performance of a new Helicobacter pylori stool antigen immunochromatographic test Vikram Kate, Mohsina Subair, Ashok Kumar Sahoo, Namrata Bhosale, Madhuvanthi Karthikeyan, Jharna Mandal, Sathasivam Suresh Kumar, Mahalakshmy Thulasingam Journal of Mahatma Gandhi Institute of Medical Sciences 2019 24(1):23-27 Introduction: Stool-based immunochromatographic test (ICT) requires validation for use in regional setups. Hence, this study was carried out to evaluate the diagnostic performance of a newly developed ICT kit (Pylori-Strip/Pylori K-Set, Corisbio). Materials and Methods: This was a prospective analytical study on patients who underwent upper gastrointestinal endoscopy. The combination of histology and urease was used as gold standard. Stool specimens were subjected to immunochromatographic stool antigen test using Corisbio stool antigen kit. The diagnostic performance of cassette and dipstick method and combination both was compared to the gold standard. Correlation of test efficacy with endoscopic, histological, and demographic parameters was carried out. Results: A total of 143 patients were included in the study. The diagnostic performance of cassette method and dipstick method was sensitivity, 73.3% (22/30) and 73.3% (22/30); specificity, 97.3% (110/113) and 98.23% (111/113); positive predictive value (PPV), 88% (22/25) and 91.66% (22/24); negative predictive value (NPV), 93.22% (110/118) and 93.27% (111/119); and overall accuracy, 92.3% (132/143) and 93% (133/143), respectively, when compared with the gold standard. The combination of the tests had a sensitivity of 73.3% (22/30), specificity of 97.3% (110/113), PPV of 88% (22/25), NPV of 93.22% (110/118), and accuracy of 92.3% (132/143). The diagnostic performance of the kit was unaffected by various demographic, endoscopic, or histological characteristics. Conclusions: The stool-based ICT is rapid and noninvasive diagnostic test with a high specificity, PPV and NPV, and overall accuracy. However, as the sensitivity is low, it should be primarily used as a rapid office test to determine eradication of Helicobacter pylori.

Evaluation of biochemical and protein biomarkers analysis in type 2 diabetes mellitus Kamal Uddin Zaidi, Firoz Naem Khan, Vijay Thawani, Richa Parmar Journal of Mahatma Gandhi Institute of Medical Sciences 2019 24(1):28-32 Introduction: Diabetes mellitus (DM) type 2 (T2) is a metabolic disorder characterized by insulin resistance and affecting protein metabolism. There has been a great interest in the proteomic analysis of plasma and serum for the identification and characterization of protein biomarkers of different diseases. Materials and Methods: For the protein identification, one of the most important developments and technologies is the proteomics. In this work, the levels of protein biomarkers specific to T2 DM using sodium dodecyl sulfate polyacrylamide gel electrophoresis were identified and characterized. Results: Patients suffering from DM and normal healthy controls were recruited for this study. Biochemical and proteins biomarker assay were done. Some proteins were up and down-regulated in the samples of diabetes as compared to control. Conclusion: Assessment of the levels of biomarkers can aid early diagnosis and as well cure of T2DM.

Evaluation of the antimicrobial property of green tea extract and its synergistic effect on antimicrobials showing resistance in clinical isolates of a tertiary care hospital Vidushi Chaturvedi, Shilpa Navinchandra Kaore, Navinchandra Motiram Kaore, Surender Kaur, Shantaram K Gautam Journal of Mahatma Gandhi Institute of Medical Sciences 2019 24(1):33-38 Background: Antimicrobial resistance is a global health challenge with the increasing drug-resistant organisms even in community. Hence, there is a need for search of other alternatives to the antimicrobials which can replace or boost the activity of existing antimicrobials. Camellia sinensis (C. sinensis) is one of the most popular beverages worldwide and has been reported to demonstrate the antimicrobial activity against various pathogenic bacteria. Aim: The aim is to evaluate the antimicrobial property of green tea extract and its synergistic effect on antimicrobials showing resistance in clinical isolates. Materials and Methods: This cross-sectional, prospective, analytical study was conducted after due approval from the Institutional Ethics Committee. Green tea was procured and shade dried, and extraction was done by percolation and infusion method. The antimicrobial activities of these extracts were studied against standard strains and then on nonrepetitive clinical isolates from bacteriology laboratory showing resistance to the primary line of antimicrobials. Results: Our study showed antimicrobial action of green tea extract by percolation method against standard strain of Pseudomonas aeruginosa but not against Escherichia coli or Staphylococcus aureus. Minimum inhibitory concentration and minimum bactericidal concentration of green tea were found to be 12.5 μg/ml against standard strain of P. aeruginosa. The green tea extract exhibited synergistic activity against 21/30 clinical strains of nonfermenters tested from various clinical samples. No antibacterial action was found for extract prepared by infusion method against the standard American Type Culture Collection strains. Conclusion: C. sinensis could be explored as one of the alternatives or for synergistic action in combination with other antimicrobials for nonfermenters. Further investigation for potential toxicity and pharmacodynamic profile of the polyphenols is required.

Rheumatology

But I Have Promises to Keep…… Vikas Agarwal Indian Journal of Rheumatology 2019 14(1):1-1

Challenges in assessing the disease activity of takayasu arteritis Durga Prasanna Misra, Anupam Wakhlu Indian Journal of Rheumatology 2019 14(1):2-3

Is rituximab "The Wonder Drug" for antineutrophil cytoplasmic antibodies-associated vasculitis? Saket Jha, GSRSNK Naidu, Aman Sharma Indian Journal of Rheumatology 2019 14(1):4-6

Advanced therapies for inflammatory rheumatic diseases in resource-poor settings Vinod Chandran Indian Journal of Rheumatology 2019 14(1):7-8

Utility of CD64 expression on neutrophils as a marker to differentiate infectious versus noninfectious disease flares in autoimmune disorders Ashutosh K Mangalam, Rajwardhan Yadav Indian Journal of Rheumatology 2019 14(1):9-11

Rituximab in relapsed/refractory antineutrophil cytoplasmic antibody associated vasculitis: A single-center prospective observational study Ekbote Gayatri, Tanna Dhaval, Negalur Natasha, Bindroo Muzaffar, Raval Dhiren, Sharma Lucky, Rajiva Gupta Indian Journal of Rheumatology 2019 14(1):12-16 Background: Induction with cyclophosphamide (CYC) and glucocorticoids in antineutrophil cytoplasmic antibody-associated vasculitis (AAV) has a relapse of 30%–50%. Studies show that rituximab (RTX) is superior to CYC in refractory/relapsed AAV. We prospectively analyzed efficacy and safety of RTX in CYC-failed cases of AAV. Methods: Patients with AAV who relapsed or were refractory to CYC therapy were given RTX 1 gm at 0 and 15 days, followed by maintenance with 500 mg every 4–6 months. All patients received oral prednisolone. Disease activity was defined by Birmingham Vasculitis Activity Score/Wegener's granulomatosis (BVAS/WG). Remission was defined by the European League Against Rheumatism criteria. Results: From August 2012 to July 2018, 67 patients with AAV were seen at our center; 21 patients who relapsed after inductions with CYC or were refractory to CYC received RTX; 8 (38%) were refractory and 13 (62%) were relapsed AAV; 20 were anti-proteinase 3 positive and 1 was anti-myeloperoxidase positive. All were granulomatosis with polyangiitis (GPA). Mean time to relapse was 12.04 ± 7.8 months. Most common indication for RTX was lung followed by ophthalmic, renal, ear nose throat, and nervous system involvement. Median follow-up after induction with RTX was 24 months. Mean BVAS/WG was 11.2 at baseline, 0.66 at the end of 3 months, 0.16 at the end of 6 months, and remained stable at that value at 18 months. At 24 months, 16 patients (76.19%) remained in remission. One was refractory to RTX treatment even after 2 years. Two patients died and two were still under follow-up. Conclusion: In our experience, RTX is a good induction and maintenance strategy for relapsed/refractory AAV.

Prescribing patterns and safety of biologics in immune-mediated rheumatic diseases: Karnataka biologics cohort study group experience Vineeta Shobha, Vijay Rao, Anu Mohan Desai, Ramesh Jois, Chandrashekara Srikantiah, BG Dharmanand, Sharath Kumar, Pradeep Kumar, Chethana Dharmapalaiah, KM Mahendranath, Shiva Prasad, Manisha Daware, Yogesh Singh, Uma Karjigi Indian Journal of Rheumatology 2019 14(1):17-20 Introduction: Biologics are widely used in Autoimmune rheumatologic diseases (AIRDs), however the need to capture real life data which monitors indications, adverse reactions cannot be over emphasized. Methods: This is a cross-sectional ambidirectional multi-center study conducted over 8 months from January 2016 to August 2016, across 12 tertiary care rheumatology centers in Karnataka, India conducted by members of the Karnataka Rheumatology Association. Results: The most common biologic prescribed is tumour necrosis factor antagonist etanercept. Commonest indication for biologics being Spondyloarthropathy group of disorders. The most common cause for stopping biologics is clinical improvement. Only 4.8% of patents discontinued biologics due to ADRs. Conclusion: The prescribing patterns, mode of use, prebiologics screening methods, and adverse event profile are similar across centres. Pre-screening for latent tuberculosis (TB) is consistent across centres, and TB prophylaxis appears to be effective in preventing its reactivation.

Pentraxin 3 is better than conventional inflammatory markers for disease activity assessment in takayasu arteritis Phani Kumar Devarasetti, Rajendra Varaprasad Irlapati, Liza Rajasekhar Indian Journal of Rheumatology 2019 14(1):21-27 Objective: The objective of this study is to measure plasma pentraxin 3 (PTX3) levels in Takayasu arteritis (TA) patients and to compare the accuracy of PTX3, high-sensitive C-reactive protein (hsCRP), and erythrocyte sedimentation rate (ESR) in distinguishing active disease from the inactive disease. Methods: In a prospective, cross-sectional study, TA patients fulfilling 1990 American College of Rheumatology criteria and healthy controls were enrolled in this study. The Indian Takayasu Clinical Activity Score (ITAS 2010) and ITAS ESR were recorded. Patients were divided into active, grumbling and inactive disease using physician global assessment. Plasma PTX3, hsCRP, and ESR were measured. Receiver operating curves for PTX3 (pg/ml), hsCRP (mg/L), and ESR (mm at 1 h) were constructed to differentiate active from the inactive disease. Inter-group comparisons were made using Mann–Whitney test. Results: Forty patients and 20 controls with median age of 26 and 24 years, respectively, were enrolled in this study. Median disease duration was 2 years. Fourteen patients had active, 8 grumbling, and 18 inactive disease. ITAS 2010 and ITAS ESR in active disease (5 [3–8.5], 7.5 [5–11.5]) were significantly higher than grumbling (0.6 (0–1.5], 2.5 [1–4.5]) or inactive disease (0.5 [0–1.3], 2 [1.7–3]) (P = 0.001). PTX3 (pg/mL) was higher in cases (505 [261–1358]) as compared to that of controls (317 [135–450]) (P < 0.026), in active disease (1335 [464–2128]) was higher than grumbling (689 [246–2114]), but significantly higher than inactive TA (369 [145–512]) (P < 0.001). ESR (mm/h) and hsCRP (mg/L) of 49 (33–61.2), 12.9 (4–21), respectively, in active disease was similar to grumbling (44 [31–63], 10.7 [3–14.7]), but significantly higher than inactive disease (38 [24–45], 1.8 [1.4–2.2]) (P = 0.03). Sensitivity, specificity, and area under the curve for ESR (>46 mm), hsCRP (17.1 mg/L), PTX3 (>745 pg/ml) was (55, 89, and 0.72), (46, 89, and 0.75), and (64, 95, and 0.82), respectively. Conclusion: Elevated PTX3 in TA demonstrates more accuracy than hsCRP and ESR in differentiating active from the inactive disease. These biomarkers may differentiate grumbling from inactive disease better than ITAS2010 or ITAS-ESR.

Serum sclerostin levels in rheumatoid arthritis and correlation with disease activity and bone mineral density Urmila Dhakad, Rasmi Ranjan Sahoo, Akhil Pawan Goel, Sourav Pradhan, Ragini Srivastava, Siddharth Kumar Das Indian Journal of Rheumatology 2019 14(1):28-31 Background: This study aims to assess serum sclerostin, an inhibitor of the Wnt/β-catenin signaling pathway, in rheumatoid arthritis (RA) and its correlation with disease activity and bone mineral density (BMD). Methods: RA patients (>18 years) fulfilling the ACR/EULAR (2010) criteria for RA were included. Postmenopausal women, those with other autoimmune diseases, secondary causes of osteoporosis, severe vitamin D deficiency, chronic liver disease, chronic kidney disease stage 3 and above, and those patients on anticonvulsants were excluded. Rheumatoid factor, anticitrullinated protein antibody, 25-OH Vitamin D estimation, plain radiographs of hands, and BMD measurement by dual-energy X-ray absorpiometry were done in patients. Disease activity was assessed by clinical disease activity index (CDAI). Serum sclerostin levels in RA patients and controls (age and sex matched) were measured by commercial enzyme-linked immunosorbent assay (ELISA) and the relationship of sclerostin with low BMD, ESR, CDAI, and erosion were explored. Results: The mean age of patients (n = 47) was 32.7 ± 6.8 years and mean disease duration was 4.2 ± 2 years. All patients were women, mean body mass index was 22.38±4.4 and mean vitamin D level was 27.9±16.4 ng/ml. 25.5% of RA patients had low BMD at least one site (Z-score: −2 or less). Serum sclerostin was significantly higher in patients compared to controls (8422 ± 3655 pg/ml vs. 6479 ± 1510 pg/ml, P = 0.002). Serum sclerostin levels did not correlate significantly with ESR (r = −0.31 and P = 0.048), CDAI (r = −0.11 and P = 0.45), BMD at lumbar spine (L1–L4, r = 0.14, and P = 0.35), femur neck (r = 0.06 and P = 0.67), and wrist (r = 0.12 and P = 0.41). Conclusion: Serum sclerostin levels were elevated in RA patients but did not correlate with disease activity and BMD.

Dual antibody status predicts sustained remission in patients with rheumatoid arthritis Praveen Pratap Jadhav, Jaya Dilip Avhad, Mahendra Mahajan, Asmanaz Mehemud Patel, Hemant Ramchandra Gavli, Janhavee Praveen Jadhav, Vaibhav Khandelwal Indian Journal of Rheumatology 2019 14(1):32-36 Background: Rheumatoid factor (RF) and anti-cyclic citrullinated protein (ACCP) estimation have been used to improve the diagnosis of rheumatoid arthritis (RA). However, their role in prognostication of RA, individually and in combination, is not well studied. This is, especially, true for Indian patients. Methods: Consecutive 945 patients who had their RF and ACCP determined were included in the study. They were followed up for 3 months to 24 months. Swollen joint count, erythrocyte sedimentation rate, disease activity score 28 (DAS 28), and Indian version of Health Assessment Questionnaire (HAQ) were checked during each visit. They were treated with conventional disease-modifying agents (DMARDS). Results: At presentation, patients with both antibodies positive had the most severe disease, while those with both antibodies negative had the least severe disease. Among discordant antibody status (one antibody positive and the other negative), patients with ACCP positivity presented with higher disease activity than with RF positivity. Patients with dual antibody positivity were much less likely to be in remission than with both negative antibodies. The percentage of patients in remission were 34.2, 29.5, 32.4, and 24.7, respectively, for RF−/ACCP−, ACCP+/RF−, ACCP−/RF+, and ACCP+/RF+. Both, ACCP (odds ratio [OR]: 0.76; 95% confidence interval [CI]: 0.74–0.78) and RF (OR: 0.68; 95% CI: 0.66–0.70) positivity were associated with lower odds of sustained remission (P < 0.05). Conclusion: Dual antibody-positive status at presentation carries poor prognosis, higher disease activity, higher HAQ score, and lesser chance of remission in RA patients with conventional treatment. Patients with both antibodies negative status had the best prognosis. Although patients with discordant antibody status had an intermediate prognosis, the ones with ACCP had higher disease activity at follow-up.

Subcuticular suture, metal clips, and steri-strips for wound closure after thyroid surgery

Comparative study of subcuticular suture, metal clips, and steri-strips for wound closure after thyroid surgery
Jnaneshwari Jayaram, CM Aruna Kumar, Rhea Pinto, Leo F Tauro

Saudi Surgical Journal 2019 7(1):10-13

Background: Pain and scar are the two important criteria bothering the patients after thyroid surgeries. Incisions on the neck when heal has to be scarless or minimum scar. Hence, we opted to study for the better methods of skin closure to obtain less pain and less scar. Aim: The study compared subcuticular suture, metal clips, and steristrips for wound closure after thyroid surgery based on the postoperative pain assessment, neck mobility, and cosmetic appearance. Materials and Methods: The prospective study which includes a consecutive series of 93 (n = 93). Patients undergoing thyroidectomy who were randomized to have their wound's closed by subcuticular sutures or steristrips or staples. The randomization code was generated using a table of random numbers, and the sealed envelope was opened at the end of each operation. Results: In this study, wound closure by steristrips had less postoperative pain followed by subcuticular suture and metal clips. In our study, neck mobility after thyroid surgery, steristrips had acceptable neck mobility compared to subcuticular suture and metalclips. In our study, cosmetic appearance after thyroid surgery wound closure with steristrips had excellent scar appearance followed by subcuticular suture and metal clips. Conclusion: In the final analysis, the choice of wound closure materials will depend on the surgeon's preference. However, this study showed that steristrips had less pain, acceptable neck mobility, excellent scar appearance followed by thyroidectomy surgery.

Gastrointestinal basidiobolomycosis (GIB)

Gastrointestinal basidiobolomycosis: An emerging potentially lethal fungal infection
M Ezzedien Rabie, Abdulla Saad Al Qahtani, Salim Jamil, Nabil Tadros Mikhail, Ismail El Hakeem, Abdelellah Hummadi, Khaled Elsayed Elshaar, Ibrahim Abdelraheem, Dib Saudi

Saudi Surgical Journal 2019 7(1):1-9

Background: Gastrointestinal basidiobolomycosis (GIB) is a newly emerging rare tropical fungal infection which affects immunocompetent individuals. Patients and Methods: Our database was reviewed to identify patients with biopsy-proven gastrointestinal basidiobolomycosis. Results: Six patients were recognized, two females and four males, with a median age of 23.5 years (range 11–70). All patients came from the same region and all had eosinophilia and they were all immunocompetent. The clinical and radiological features simulated colorectal malignancy in four patients, inflammatory bowel disease in one patient, and left iliac fossa mass in another patient. The diagnosis was established after extensive colonic surgery in four patients, after open biopsy in one patient and after ultrasound-guided biopsy in another. All patients received prolonged antifungal treatment. In those who received extensive colonic surgery, one patient died, two patients recovered, and one is still receiving antifungal treatment. Patients in whom the diagnosis was established by biopsy only, one patient recovered while the other is showing steady improvement. Conclusion: GIB is a potentially lethal fungal infection, which affects immunocompetent individuals in temperate and hot arid regions of the world, including Saudi Arabia, Iraq, Iran, and Arizona desert in the United States. The patient usually presents with features suggestive of colonic malignancy, inflammatory bowel disease, or abdominal mass. Establishing the diagnosis by endoscopic- or radiology-guided biopsy, serological tests, fungal cultures, or molecular techniques enables the institution of antifungal treatment, which may lead to complete cure without surgery. With or without surgery prolonged antifungal therapy is always required.

Surgical

Gastrointestinal basidiobolomycosis: An emerging potentially lethal fungal infection M Ezzedien Rabie, Abdulla Saad Al Qahtani, Salim Jamil, Nabil Tadros Mikhail, Ismail El Hakeem, Abdelellah Hummadi, Khaled Elsayed Elshaar, Ibrahim Abdelraheem, Dib Saudi Saudi Surgical Journal 2019 7(1):1-9 Background: Gastrointestinal basidiobolomycosis (GIB) is a newly emerging rare tropical fungal infection which affects immunocompetent individuals. Patients and Methods: Our database was reviewed to identify patients with biopsy-proven gastrointestinal basidiobolomycosis. Results: Six patients were recognized, two females and four males, with a median age of 23.5 years (range 11–70). All patients came from the same region and all had eosinophilia and they were all immunocompetent. The clinical and radiological features simulated colorectal malignancy in four patients, inflammatory bowel disease in one patient, and left iliac fossa mass in another patient. The diagnosis was established after extensive colonic surgery in four patients, after open biopsy in one patient and after ultrasound-guided biopsy in another. All patients received prolonged antifungal treatment. In those who received extensive colonic surgery, one patient died, two patients recovered, and one is still receiving antifungal treatment. Patients in whom the diagnosis was established by biopsy only, one patient recovered while the other is showing steady improvement. Conclusion: GIB is a potentially lethal fungal infection, which affects immunocompetent individuals in temperate and hot arid regions of the world, including Saudi Arabia, Iraq, Iran, and Arizona desert in the United States. The patient usually presents with features suggestive of colonic malignancy, inflammatory bowel disease, or abdominal mass. Establishing the diagnosis by endoscopic- or radiology-guided biopsy, serological tests, fungal cultures, or molecular techniques enables the institution of antifungal treatment, which may lead to complete cure without surgery. With or without surgery prolonged antifungal therapy is always required.

Comparative study of subcuticular suture, metal clips, and steri-strips for wound closure after thyroid surgery Jnaneshwari Jayaram, CM Aruna Kumar, Rhea Pinto, Leo F Tauro Saudi Surgical Journal 2019 7(1):10-13 Background: Pain and scar are the two important criteria bothering the patients after thyroid surgeries. Incisions on the neck when heal has to be scarless or minimum scar. Hence, we opted to study for the better methods of skin closure to obtain less pain and less scar. Aim: The study compared subcuticular suture, metal clips, and steristrips for wound closure after thyroid surgery based on the postoperative pain assessment, neck mobility, and cosmetic appearance. Materials and Methods: The prospective study which includes a consecutive series of 93 (n = 93). Patients undergoing thyroidectomy who were randomized to have their wound's closed by subcuticular sutures or steristrips or staples. The randomization code was generated using a table of random numbers, and the sealed envelope was opened at the end of each operation. Results: In this study, wound closure by steristrips had less postoperative pain followed by subcuticular suture and metal clips. In our study, neck mobility after thyroid surgery, steristrips had acceptable neck mobility compared to subcuticular suture and metalclips. In our study, cosmetic appearance after thyroid surgery wound closure with steristrips had excellent scar appearance followed by subcuticular suture and metal clips. Conclusion: In the final analysis, the choice of wound closure materials will depend on the surgeon's preference. However, this study showed that steristrips had less pain, acceptable neck mobility, excellent scar appearance followed by thyroidectomy surgery.

Preoperative predictors of conversion in elective laparoscopic cholecystectomy Smita Chauhan, Shakeel Masood, Anshuman Pandey Saudi Surgical Journal 2019 7(1):14-19 Introduction: Laparoscopic Cholecystectomy, the gold standard for management of gall stone disease, has a conversion rate of 1.6%-20% at different centers. We audited our elective laparoscopic cholecystectomies, to enable preoperative prediction of the probability of conversion. Method: Retrospective audit of all laparoscopic cholecystectomies from Jan 2013 to March 2017 was done. The cases that required conversion to open cholecystectomy were evaluated for pre- and intraoperative factors responsible for conversion and statistically analyzed using SPSS version 23 [IBM, USA]. Results: 764 patients (mean age 42.9 years) were taken up for laparoscopic cholecystectomies of which 33(4.31%) were converted to open cholecystectomy. The operative factors responsible for conversion were: (1) the presence of dense pericholecystic adhesions (P<0.001), (2) frozen Callot's triangle (P=0.013), (3) unclear anatomy (P=0.002) and iatrogenic injury to CBD (n=2), or bowel (duodenum and colon n=1). Pre-operative factors associated with conversion included age>60y (P=0.032), male sex (P=0.17), history of fever (P<0.032), prior ERCP (P=0.012) and anatomy complicated by cholecystoenteric fistula or Mirrizi's syndrome (P<0.001) Sonographic findings of contracted GB, thick walled GB, and stone impacted at neck of gallbladder were found to have high predictive value for conversion (P<0.001). Conclusion: Male sex, Age>60years, history of fever with pain, Mirrizi's syndrome, prior ERCP, ultrasound finding of a contracted gallbladder, thick walled gallbladder, and/or stone impaction at neck of gallbladder, significantly predispose to conversion at laparoscopic cholecystectomy. These preoperative factors translate intra-operatively into an unclear anatomy (suggesting that recurrence of inflammation causes increased fibrosis and unclear anatomy at Calot's) predisposing to a higher conversion rate.

Inguinal herniotomy: A national survey Osama Abdullah Bawazir Saudi Surgical Journal 2019 7(1):21-25 Objectives: The objective of this study was to evaluate and describe the current practice of surgical repair of inguinal herniotomy among pediatric surgeons working in Saudi Arabia. Materials and Methods: Between May and June 2018, a questionnaire of 15 multiple choices was sent to all pediatric surgery consultants working in pediatric surgery units across the kingdom of Saudi Arabia. The responses to the questionnaire were analyzed and categorized as shown in the results section. Results: A total of 215 questionnaires were sent, over half of the practitioners fill the questionnaire 56.3% (121). With fair distribution, among type of hospitals were 33% in children hospital, 33% in tertiary hospital, 7% in private hospital, and 8% in general or academic hospitals. Regarding the diagnosis, almost all the surgeons depend on the mother history of a swelling in the groin that comes and goes. The majority (97%) of surgeon will do a standard open herniotomy for male infants, and only 2% will do laparoscopic hernia repair. For ex-premature infants with an inguinal hernia and already discharged from the neonatal intensive care unit, 35% will repair the hernia at presentation regardless of the age, 27% will do it after 50 weeks of postmenstrual age, 18% will do it after 60 weeks of postmenstrual age, 12% will do it after 2 months or above 5 kg weight, and only 8% will do it on urgent basis. Conclusions: The majority of pediatric surgeons depend on a clinical diagnosis of inguinal hernia. Although the timing of surgical repair is still controversial, the majority of pediatric surgeons will repair inguinal hernia as soon as possible. Still, there is no consensus on when or if contralateral inguinal exploration is necessary.

Pretreatment clinical, laboratory, and imaging predictors of the outcome of pneumatic reduction of pediatric idiopathic ileocolic intussusception Alaa E Younes, Mohamed Al Saeed, Bilal O Al-Jiffry, Tamer Abdel-Rahman, Samir Badr, Aseel Abu-Duruk, Mohamed Hatem Saudi Surgical Journal 2019 7(1):26-31 Background/Purpose: Air enema reduction is considered by many authors to be the first line of treatment of idiopathic pediatric ileocolic intussusception. The aim of this retrospective study was to evaluate the results of the pneumatic reduction in our hospitals as a treatment of idiopathic pediatric ileocolic intussusception and to identify the pretreatment factors associated with pneumatic reduction failure. Methods: This was a multicenter chart review and database retrospective study conducted in tertiary general hospitals in Taif, Saudi Arabia. The study was conducted by revising the medical records of all pediatric patients who were admitted to the hospitals with picture suggestive of intussusception from January 2007 to December 2017. A total of 235 children were proved to have idiopathic ileocolic intussusception and initially treated by air reduction (AR) under fluoroscopic guidance. The primary outcome was the results of pneumatic reduction, and the secondary outcome was to identify the pretreatment factors associated with pneumatic reduction failure. Results: A total of 235 patients with male-to-female ratio 3:1 were included in the study with a mean age of 18.6 ± 4.3 months. The AR was successful in 87.2% of cases, perforation occurred in 0.9%, and the recurrence within the first 48 h was 6.3%. The risk factors which were significantly correlated with failed reduction were duration of symptoms >48 h, rectal bleeding, hemoglobin level <11.9 gm, neutrophils >66.8% of total neutrophil count, ultrasound poor prognostic signs, and body weight <11.7 kg. Conclusion: AR is safe and effective as a first-line treatment for pediatric idiopathic intussusception. A delay in presentation, presence of rectal bleeding, a high segmental neutrophils, low hemoglobin level, and low body weight, or/and presence of ultrasound bad prognostic signs, might be associated with reduction failure. The presence of these predictors of failure does not contraindicate the pneumatic reduction; however, the procedure should be carefully performed to avoid irreducibility and the risk of bowel perforation.

Successful use of octreotide and limited drainage in resistant chylothorax in congenital diaphragmatic hernia Rajendran Ramaswamy, Krishna R Gopala, Saif Saeed Mohamed Galib, Samir Morsi Hegab Saudi Surgical Journal 2019 7(1):32-35 In the conservative treatment of postdiaphragmatic hernia chylothorax, use of octreotide (OCT) had variable results. Limited chyle drainage has not been tried. A newborn, after the left Bochdalek diaphragmatic hernia repair, developed chylothorax. Treatment with intercostal chest tube (ICT) drainage, partial parenteral nutrition (PPN), and medium-chain triglyceride (MCT) with formula feeds was ineffective. ICT slipped out on the 13th day in the presence of significant residual chylothorax. Further drainage was not done. Addition of OCT infusion at maximum dose of 6 μg/kg/h cleared the chylothorax. No side effect of OCT was observed. The present case has proved that MCT feeding along with PPN is effective, and limited drainage of chyle is enough with OCT treatment in postdiaphragmatic hernia chylothorax.

Aortoesophageal fistula postthoracic endovascular aortic repair Abdulrhman Hassan, Abdullah Alhaizaey, Musaad Alghamdi Saudi Surgical Journal 2019 7(1):36-37 Thoracic endovascular aortic repair (TEVAR) is one of the choices for management of thoracic aortic aneurysms.[1] However, the complications of this procedure remain undetermined.[1] We present a 91 years male with a fatal post TEVAR aortoesophageal pseudoaneurysm leak and fistula to draw attention for such complication and its primary symptoms that may provide immediate treatment.

Leiomyoma of the hand Feras Altumaihi, Hattan Aljaaly, Hossam Ammar, Basem Awan Saudi Surgical Journal 2019 7(1):38-40 Leiomyoma is a benign tumor of the uterine smooth muscle that occurs in approximately half of all women by the age of 50 years. However, these tumors occasionally occur in other parts of the body. A 27-year-old woman presented with a painless, slow-growing nodule on her right index finger that had increased in size to 1.6 cm × 1.4 cm × 1.2 cm. The initial diagnostic hypotheses included a ganglionic cyst and giant cell tumor. However, surgical excision and histological analysis revealed this tumor to be a leiomyoma of the hand.

Erratum: Factors influencing decision of medical students in choosing a surgical specialty: A cross-sectional study Saudi Surgical Journal 2019 7(1):41-41

Ultrasound Guided Needle Placement in Sacroiliac Joint Injections

Assessing the Accuracy of 
Objective The aim of this study was to assess the accuracy of ultrasound guided needle placement for sacroiliac joint injections. Design Institutional Review Board (IRB) approval was gained for a prospective cohort study of fifty patients (N=50). Study patients who were referred for sacroiliac joint injections for sacroiliac joint mediate pain, and met inclusion/exclusion criteria, were enrolled in the study. Each patient underwent needle placement with ultrasound guidance in the procedure suite. After the needle was placed with the ultrasound guidance, fluoroscopy was utilized to confirm correct placement via contrast injection confirming a sacroiliac joint arthrogram. The arthrogram was confirmed via the performing physician and radiologist. Results The placement of the needle with ultrasound guidance into the sacroiliac joint was confirmed successful in 96% (48/50) patients by fluoroscopic arthrogram. The two patients with unsuccessful arthrograms following initial placement of the needle with ultrasound were morbidly obese. There was intra-vascular uptake during the arthrogram of one patient who had a successful arthrogram. Conclusions Ultrasound-guided injection of the sacroiliac joint is successful and accurate upon confirmation of fluoroscopic arthrogram and should be utilized as an imaging modality for needle guidance. Correspondence: Arthur Jason De Luigi, DO, MHSA, 10825 N. 140th Way, Scottsdale, AZ 85259, 301793-2136, ajweege@yahoo.com Competing Interests-None for any author Funding or grants or equipment provided for the project from any source-None for any author Financial benefits to the authors-None to any author Details of any previous presentation of the research, manuscript, or abstract in any form: None Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.