Tuberculosis verrucosa cutis in a patient with keloid over ear lobule

Tuberculosis (TB) is a global health problem with predominance in resource-poor countries. Extrapulmonary TB constitutes approximately 10% of the cases and can present as different forms depending on the route of entry. Cutaneous TB is a small subset of the extrapulmonary TB. Cutaneous TB can either be of primary origin or secondary origin or it can be a part of a systemic infection. TB verrucosa cutis (TBVC) is the exogenous reinfection of TB in a previously sensitised patient. Routine cultures do not have a high yield in TBVC due to the paucibacillary nature of the organism. Here we are presenting a rare case of a patient who developed in a keloid over the right ear lobule following ear piercing. This has only been presented once in the previous literature and for the first time in the head and neck region

Quality of life after functional endoscopic sinus surgery in patients with chronic rhinosinusitis

Chronic Rhinosinusitis (CRS) is a group of disorders characterized by the inflammation of mucosa of the nasal passages and paranasal sinuses. It includes chronic rhinosinusitis with polyps, CRS without polyps and Allergic Fungal Sinusitis (AFS). This debilitating disease causes negative impact on quality of life (QOL) of patients. Functional endoscopic sinus surgery (FESS) is the mainstay of surgical treatment for patients and improves QOL of patients. This subjective assessment of QOL can be measured by disease specific questionnaires. SNOT-22 questionnaire is widely used and validated questionnaire for this purpose. Prospective study was done on 54 patients. Data were collected using SNOT-22 questionnaire and filled in pre-operative period then in post-operative follow-up visits on 1st, 3rd, 6th and 12th months. Paired sample t-test was used to compare pre-operative and post-operative SNOT scores and multivariate generalized linear model was used to estimate regression parameters for SNOT scores in CRS with polyp and AFS in comparison of CRS without polyps. Out of 54 patients, 59.3% were males, mean age was 35.98, 29.6% were in CRS without polyp group, 44.4% and 25.9% were in CRS with polyps and AFS group. Recurrence occurred in 7.4%, revision surgery required in 3.7% while 22.2% had history of asthma. Paired sample t-test showed statistical significant reduction in post-operative SNOT scores. Linear model results showed SNOT scores in CRS with polyp group was significantly reduced. Thus FESS provides significant improvement in QOL of patients in chronic rhinosinusitis

Hepatoprotective Effect of Berberis Lycium in Αlpha-Naphthylisothiocyanate Induced Cholestatic Mouse Models

Cholestasis is characterized by the obstruction of bile flow from hepatocytes to the intestine. It results in accumulation of bile acids in the liver, which cause oxidative stress, inflammation, apoptosis, fibrosis, and cirrhosis. Till now, the treatment options against cholestasis are limited. Therefore, there is an utmost requirement to develop and evaluate the drugs with potential anti-cholestatic effects. In the current study, the drug-induced cholestasis mouse models were generated via oral administration of α-naphthylisothiocyanate (ANIT). The mice were placed into three groups of six animals each. Group I was the control group and was given saline. The cholestasis model Group II was given saline for 19 days. On 19th day (48 hours before sacrifice) they received a single dose of ANIT (75 mg/kg). Group III served as the plant extract treatment group and received root extract for 19 days. On nineteenth day (48 hours before sacrifice) they received a single dose of ANIT (75 mg/kg). On 21st day, mice were sacrificed for analysis of serum biochemistry and liver histology. The results revealed that Berberis lycium extract has hepatoprotective properties, as serum level of AST (aspartate aminotransferase) and ALT (alanine transaminase) are significantly lower in the plant treatment group compared to the cholestasis model group. Furthermore, liver histology validated the serological results since the hepatocyte architecture in the plant treatment group was similar to that of control group. In conclusion, the data exhibit that B. lycium possess protective activities against ANIT induced cholestasis

Fundus topographical distribution patterns of ocular toxoplasmosis

BACKGROUND: To establish topographic maps and determine fundus distribution patterns of ocular toxoplasmosis (OT) lesions. METHODS: In this retrospective study, patients who presented with OT to ophthalmology clinics from four countries (Argentina, Turkey, UK, USA) were included. Size, shape and location of primary (1°)/recurrent (2°) and active/inactive lesions were converted into a two-dimensional retinal chart by a retinal drawing software. A final contour map of the merged image charts was then created using a custom Matlab programme. Descriptive analyses were performed. RESULTS: 984 lesions in 514 eyes of 464 subjects (53% women) were included. Mean area of all 1° and 2° lesions was 5.96±12.26 and 5.21±12.77 mm2, respectively. For the subset group lesions (eyes with both 1° and 2° lesions), 1° lesions were significantly larger than 2° lesions (5.52±6.04 mm2 vs 4.09±8.90 mm2, p=0.038). Mean distances from foveola to 1° and 2° lesion centres were 6336±4267 and 5763±3491 µm, respectively. The majority of lesions were found in temporal quadrant (p<0.001). Maximum overlap of all lesions was at 278 µm inferotemporal to foveola. CONCLUSION: The 1° lesions were larger than 2° lesions. The 2° lesions were not significantly closer to fovea than 1° lesions. Temporal quadrant and macular region were found to be densely affected underlining the vision threatening nature of the disease

Reducing the rates of central line associated blood stream infection using comprehensive unit-based safety program model in the ICU of a tertiary care hospital in Pakistan

Background: Current conceptual thinking about patient safety places the primary responsibility for adverse events on deficiencies in system design, organization, and operation rather than on individual practitioners or products. Countermeasures based on changes in the system are, therefore, more productive than those that target the behavior of individuals and their propensity to commit errors. The World Health Organization (WHO) acknowledges that to tackle patient safety internationally, a comprehensive, multifaceted approach involving cultural change, system development and technical expertise is necessary. Central line-associated bloodstream infection (CLABSI) is a primary infection arising from the central line. CLABSI are common, costly, and potentially lethal. A recent meta-analysis by the WHO estimated that pooled cumulative incidence densities of leading causes of HCAIs like central-line associated blood stream infections among adult ICU patients in developing countries was 12.2 per 1000 central line days. Not only are these rates 2-3 fold higher than in ICUs in developed countries, one report showed a crude unadjusted excess mortality of 14.7% to 23.6% from CLABSIs in adult ICU patients. Methods: The Project was implemented in February 2011 in the 10 bedded adult ICU which receives medical and surgical critically ill patients except patients who have cardiothoracic surgical morbidity. The staff of the unit was given orientation to the CUSP project and patient safety assessment was done. Education and training was initiated for CLABSI to emphasize patient safety; hand washing certification was also done. A team was selected to follow up the patients with central lines and observe their outcomes. Central line insertion kit and checklists were developed and to reinforce the staff compliance with the insertion checklist, spot checks were done. Full body drape of patients during line insertion was reinforced and ultrasound machine was made available in the unit to prevent extra pricks. Femoral line avoidance, skin cleaning with 2 % chlorhexidine, removal of unnecessary lines and use of maximal barrier precautions were the steps that were undertaken at the time of insertion. Maintenance check list with daily goal sheets were observed by the ICU staff. The pre-intervention period was from January, 2009 to January, 2011 and the post-intervention period was from the February, 2011 up till November, 2012. Results: The number of central line infections for pre-intervention period was 45 with 7925 CL-days and for the post-intervention period there were 14 central line infections with 5129 CL-days. The CLABSI rate decreased from 5.68 per 1000 CL-days (95% confidence interval, 3.75-8.3), for the pre-intervention period, to a post-intervention rate of 2.73 per 1000 CL- days (95% confidence interval, 1.25-3. .99) signifying an approximate 52% reduction in CLABSI incidence from baseline (Incident rate ratio, 0.48; 95% confidence interval, 0.24-0.89; p = 0.013). Conclusions: A multidimensional strategy like CUSP can be effective in achieving significant and sustained reductions in CLABSI rates. Key words: patient safety, CUSP, CLABS

RETRACTED ARTICLE: Pharmacological agents in development for diabetic macular edema

[No Abstract Available

Aspiration in injections: should we continue or abandon the practice? [version 3; referees: 2 approved]

Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure. While aspiration appears to be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, there is no evidence that this procedure is truly beneficial or unwarranted. Keeping in view the huge number of injections given worldwide, it is important that we draw attention to key questions regarding aspiration that, up till now, remain unanswered. In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order to provide not only an exhaustive review of the subject, but also a starting point for further studies on more specific areas requiring clarification. A literature review was conducted using the US National Institute of Health’s PubMed service (including Medline), Google Scholar and Scopus. Guidelines provided by the World Health Organization, Safe Injection Global Network, International Council of Nursing, Center for Disease Control, US Federal Drug Agency, UK National Health Services, British Medical Association, Europe Nursing and Midwifery Council, Public Health Agency Canada, Pakistan Medical Association and International Organization of Standardization recommendations 7886 parts 1-4 for sterile hypodermics were reviewed for relevant information. In addition, curricula of several medical/nursing schools from India, Nigeria and Pakistan, the US pharmacopeia Data from the WHO Program for International Drug Monitoring network in regard to adverse events as a result of not aspirating prior to injection delivery were reviewed. Curricula of selected major medical/nursing schools in India, Nigeria and Pakistan, national therapeutic formularies, product inserts of most commonly used drugs and other possible sources of information regarding aspiration and injections were consulted as well

Alendronate induced chorioretinitis: The importance of meticulous assessments

Purpose: To report a case of presumed bilateral chorioretinitis secondary to alendronate therapy. Observations: A 71-year-old female presented to the clinic in July 2017 with six months history of difficulty in reading along with floaters in both eyes which were more severe in the right eye. Past medical and surgical history revealed a history of hypertension, gout, hyperthyroidism, osteoporosis, and humerus fracture. She was started on alendronate three months before developing ocular symptoms. On ocular examination, best corrected visual acuity was 20/30 in the right and 20/25 in the left eye. Slit-lamp examination demonstrated normal anterior chamber examination in both eyes. Dilated fundus examination revealed geographic chorioretinal lesions around the optic nerve head in both eyes, more extensively in the right eye; and superior and temporal to the macula in the right eye. Past ocular records in February 2015 did not reveal any such findings. Fundus autofluorescence demonstrated hyper-autofluorescence in the peripapillary lesions in both eyes. The lesion adjacent to the macula in right eye displayed mixed hyper and hypo-autofluorescence. Fluorescein angiography showed combined hyper- and hypo-fluorescence compatible with window defect, staining and blockage. However, no leakage was appreciated in the macula, peripapillary, and peripheral lesions in both eyes. Optical coherence tomography scan showed septate hyporeflective intraretinal spaces in the right eye. Conclusion and importance: The index report underscore the importance of considering alendronate as an etiologic cause of chorioretinitis, especially in subjects with atypical lesions developing after alendronate therapy. We, therefore, recommend discontinuation of this medication in subjects who develop chorioretinitis after employing this medication. Keywords: Uveitis, Drug-induced, Alendronate, Chorioretinitis, Bisphosphonate

Evaluation of macular and peripapillary vessel flow density in eyes with no known pathology using optical coherence tomography angiography

Abstract Purpose To assess normal vessel flow density (VFD) in macular and peripapillary regions of eyes with no known ocular pathology using optical coherence tomography angiography (OCTA). Methods AngioVue (Optovue, Fremont, CA, USA) was used to capture OCTA images. A 3 × 3 mm grid and a 4.5 × 4.5 mm grid was used to scan parafoveal and peripapillary regions, respectively. ReVue software was utilized to measure VFD in five sectors within the inner two circles of ETDRS grid in macular region and correlated to retinal thickness of same sectors. At optic disc, VFD was calculated in six sectors based on Garway-Heath map. Area and morphology of foveal avascular zone (FAZ) was correlated with VFD in central 1 mm. The influence of myopia on mean VFD was also assessed. Results Twenty-four eyes (mean age: 30 years) were analyzed. Mean VFD in macular sectors was 43.5 (±4.5) and 45.8 (±5.0) % in superficial and deep retinal plexuses, respectively. Mean VFD was significantly higher in deep retinal plexus compared to superficial retinal plexus in all sectors except central 1 mm (p < 0.05). Mean VFD in central 1 mm increases with an increase in central retinal thickness in both superficial and deep retinal plexuses (p < 0.001). Mean parafoveal VFD at level of both superficial and deep retinal plexuses decrease with an increase in spherical equivalent in myopics (p < 0.05). Mean VFD in myopics was found to be significantly lower in parafoveal region of deep retinal plexus (p < 0.05). Mean area of FAZ was 0.33 (±0.15) and 0.47 mm2 (±0.15) in superficial and deep retinal plexuses, respectively. Area of FAZ decreases with an increase in central 1 mm thickness and foveal VFD (p < 0.001). Conclusions OCTA may be used to measure VFD in macular and peripapillary regions. Vessels in the parafoveal region are more densely packed in the deep retinal plexus leading to higher VFD compared to superficial plexus. Thicker retina in fovea translates into higher foveal VFD due to more compact arrangement of retinal layers and continuity of inner nuclear layer (INL). Myopia is associated with lower VFD in parafoveal region at level of deep retinal plexuses which may explain thinning of INL in myopics

Diurnal variation of choriocapillaris vessel flow density in normal subjects measured using optical coherence tomography angiography

Abstract Background Vessel flow density (VFD) may provide important information regarding perfusion status. Diurnal variation in VFD of choriocapillaris has not been reported in literature. In the index study, optical coherence tomography angiography (OCTA) was used to assess the diurnal variation of the VFD in the choriocapillaris of subjects with no known ocular disease. Methods Fifty eyes with no known ocular disease (25 subjects) were included. OCTA images were acquired using AngioVue (Optovue, Fremont, CA, USA) at two different time points on a single day: 9:00 AM and 6:00 PM. Macular cube scan protocol (3 × 3 mm) centered on the fovea was used. Automatic segmentation of the retinal layers and choriocapillaris was performed using ReVue software, which was also used to measure the choriocapillaris VFD. Horizontal line scan passing through fovea was obtained by the device at both time points to measure the subfoveal choroidal thickness (CT). Linear measurement tool of software was used to measure subfoveal CT according to a standardized reproducible method. Wilcoxon signed-rank test was used to assess the differences in choriocapillaris VFD and subfoveal CT at the two time points. Correlation between change in choriocapillaris VFD and subfoveal CT at the two time points was assessed using the Pearson correlation coefficient (r). Results The mean age of the subjects was 31.96 ± 11.23 years. Choriocapillaris VFD was significantly higher at 9:00 AM compared to 6:00 PM (P < 0.0001) with mean choriocapillaris VFD of 68.74 ± 4.80% at 9:00 AM and 67.57 ± 5.41% at 6:00 PM, with a mean diurnal amplitude of 1.17%. Mean subfoveal CT was 287.74 ± 61.51 µm at 9:00 AM and 270.06 ± 60.73 µm at 6:00 PM. Subfoveal CT was also significantly higher at 9:00 AM compared to 6:00 PM (P < 0.0001) with a mean diurnal amplitude of 17.68 µm. Change in choriocapillaris VFD correlated with change in subfoveal CT (r = 0.87, P < 0.001). Conclusion OCTA demonstrated significant diurnal change in choriocapillaris VFD in subjects without any ocular disease with VFD being higher in the morning and lower in the evening. Decrease in choriocapillaris VFD in the evening correlated with a reduction in subfoveal CT