Prescribing practices of tranexamic acid for melasma: Delphi consensus from the Pigmentary Disorders Society

Introduction There is ambiguity regarding usage of tranexamic acid for melasma in India, be it in its pre-administration evaluation, administration route, dosing or monitoring. Hence, we conducted this study to understand various tranexamic-acid prescribing patterns and provide practical guidelines. Materials and methods A Google-form-based questionnaire (25-questions) was prepared based on the key areas identified by experts from the Pigmentary Disorders Society, India and circulated to practicing dermatologists across the country. In rounds 2 and 3, the questionnaire was re-presented to the same group of experts and their opinions were sought. The results of the practitioners' survey were denoted graphically alongside, to guide them. Consensus was deemed when at least 80% of respondents chose an option. Results The members agreed that history pertaining to risk factors for thromboembolism, cardiovascular and menstrual disorders should be sought in patients being started on oral tranexamic-acid. Baseline coagulation profile should be ordered in all patients prior to tranexamic-acid and more exhaustive investigations such as complete blood count, liver function test, protein C and S in patients with high risk of thromboembolism. The preferred oral dose was 250 mg orally twice daily, which can be used alone or in combination with topical hydroquinone, kojic acid and sunscreen. Repeated dosing of tranexamic-acid may be required for those relapsing with melasma following initial tranexamic-acid discontinuation. Coagulation profile should ideally be repeated at three monthly intervals during follow-up, especially in patients with clinically higher risk of thromboembolism. Treatment can be stopped abruptly post improvement and no tapering is required. Limitation This study is limited by the fact that open-ended questions were limited to the first general survey round. Conclusion Oral tranexamic-acid provides a valuable treatment option for melasma. Frequent courses of therapy may be required to sustain results and a vigilant watch is recommended for hypercoagulable states during the course of therapy.

Association of Posterior Reversible Encephalopathy Syndrome (PRES) with Preeclampsia with Severe Symptoms and Eclampsia in South East Part of Bangladesh

Posterior reversible encephalopathy syndrome (PRES) is a pathology seen not only in precelampsia with severe symptoms and eclampsia but in a varicty of diseases/ conditions. With the availability of neuroimaging, it is possible to know the exact underlying Central nervous system (CNS) pathology in preeclampsia with severe symptoms and eclampsia and thus therapy can be targeted. Preeclampsia with severe symptoms and eclampsia remains to be an important cause of maternal morbidity and mortality in both the developing and developed world. The objective of this study was to evaluate the association of Posterior reversible encephalopathy syndrome (PRES) by MRI (Magnetic resonance imaging) with preeclampsia with severe symptoms and eclampsia in south east part of Bangladesh. This cross-sectional observational study was performed among women suffering from preeclampsia with severe symptoms and eclampsia who attended at Obstetrics & Gynaecology department of Chittagong Medical College Hospital (CMCH), Bangladesh from January 2021 to June 2021. According to inclusion/exclusion criteria 50 samples were taken by convenient sampling for this study. A detail history was taken and complete general physical and gynecological examination was performed. Required data was collected through preset questionnaire. Neuroimaging reports were reviewed by both neurologist and radiologist. Data was analyzed by using windows based computer software device, SPSS 25.0. Results obtained from this study will be used to make a statement regarding aggressive management for cerebral vasospasm in severe preeclampsia and eclamptia related PRES. PRES has been reported to be reversible but late recognition or incorrect treatment can cause irreversible brain damage. Institution of early treatment leads to resolution of symptoms without any neurologic deficit and thus reduces maternal morbidity and mortality. PRES is a cliniconeuroradiologic entity. This study can aware doctors regarding prompt diagnosis of PRES in peripartum period among patient suffering from preeclampsia with severe symptoms and eclampsia by imaging aside clinical findings. A conclusive decision can be made to improve the outcome in this potentially life threatening but reversible condition.

Impact of COVID-19 Pandemic on Dermatology Teaching Program in India: A Survey on the Faculty and Residents' Perspective

Background

Impact of COVID-19 pandemic has been immense. An innocent casualty of this disaster is medical education and training. Dermatology, which primarily deals with out-patient services, medical and surgical interventions, and in-patient services, was one of the worst hit. The National Medical Commission of India has implemented competency-based medical education (CBME) in Dermatology, Venereology, and Leprosy since 2019. The new curriculum relies on acquiring practical and procedural skills, training skills in research methodology, professionalism, attitude, and communication.

Objectives

The study was undertaken to understand the implications of the COVID-19 pandemic on postgraduate dermatology CBME training in India.

Materials and Methods

A questionnaire-based survey was carried out on postgraduate dermatology teachers and residents in India after obtaining ethics committee approval. An online semi-structured English questionnaire was administered by Google Forms. The calculated sample size was 366 dermatology faculty and 341 postgraduate students. Validity (Content validity ratio (CVR) ≥0.56) and reliability (Cronbach's alpha coefficient 0.7249) of the questionnaire were determined.

Results

Among the 764 responses received, 51.4% reported that their institutes were converted to exclusive COVID hospitals. Domains of dermatology education affected were procedural training (n = 655), bedside clinical teaching (n = 613), outpatient department-based clinical teaching (n = 487), bedside laboratory procedures (n = 463), research activities (n = 453), histopathology (n = 412), and theory classes (n = 302). To keep up with the teaching-learning process, online platforms were mostly utilized: Zoom Meeting (n = 379), Google Meet (n = 287), and WhatsApp Interaction (n = 224). Teaching during ward rounds was significantly more affected in exclusively COVID institutes than non-exclusive COVID institutes (P < 0.001). Psychomotor skill development suffered a major jolt with 26.7% of respondents reporting a standstill (P < 0.001). Communication skills among students suffered due to social distancing, mask, and poor attendance of patients. According to 23.84% of respondents, formative assessment was discontinued.

Conclusion

Online seminars, journal clubs, and assessments have been incorporated during the pandemic. Online modalities should be used as a supplementary method as psychomotor skills, communication skills, research work, and bedside clinics may not be replaced by the e-learning.

Psychiatric Morbidities and Their Impact on Quality of Life in Patients With Psoriasis

Background Psychiatric morbidities, which are commonly seen in psoriasis patients, are often missed or ignored leading to poor quality of life. A lack of communication between psychiatrists and dermatologists leads to ignorance of psychiatric morbidities in psoriasis patients, which can eventually take a severe form. Therefore, both groups must collaborate to provide high-quality patient care. As there is a dearth of such studies in the North-Eastern part of India, this study aimed to highlight the above-mentioned problem. Aim The aim of this study was to study psychiatric morbidities in patients with psoriasis and to compare quality of life in psoriasis patients with and without psychiatric morbidities. Methods This study was a hospital-based cross-sectional study conducted in the Dermatology Department, Assam Medical College and Hospital, Dibrugarh, Assam, India from July 2020 to July 2021. Ninety patients with psoriasis were included in the study and the diagnosis was confirmed by a consultant dermatologist, then the Mini International Neuro-psychiatric Interview Scale (M.I.N.I.; version 5.0) scale was applied to screen psychiatric morbidities. The diagnoses were confirmed using ICD-10 followed by dividing psoriasis patients into two groups, i.e. with and without psychiatric morbidities. After that the World Health Organization Quality of Life (WHOQOL) scale was applied to both groups and the domains of quality of life were compared. Results Our results showed that 61.1% of psoriatic patients had psychiatric morbidities, which is abnormally high compared to other dermatological disorders. The psychological domain of quality of life was the most affected (WHOQOL scale scoring of 38.12±6.67 vs. 48.76±6.21) in both groups of patients (i.e., with and without psychiatric morbidities), and the environmental domain was the least affected (56.67±10.65 vs. 64.67±8.18). Every domain of quality of life had a lower score in patients with psoriasis with psychiatric morbidities as compared to those without (p<0.05). Conclusion Our results of 61.1% psychiatric morbidities in psoriasis patients emphasize the need for psychiatric evaluation in every psoriasis patient. The timely intervention of psychiatric morbidity in psoriasis patients with collaboration of psychiatrists and dermatologists will surely improve the patient's condition to some extent and, thus, their quality of life.

Management of Dermatophytosis: Real-World Indian Perspective

Background

In spite of the availability of multiple consensus statements on dermatophytosis management, different treatment approaches have been experienced in India and require more scrutiny to further update guidelines and improve patient care.

Aim

To determine the different approaches in dermatophytosis diagnosis and management among dermatologists in India.

Materials and Methods

A web-based questionnaire was created and validated by five panelists with experience of >15 years in dermatophytosis and then circulated to about 2,000 dermatologists in India in September 2021 for a real-world management scenario.

Results

Out of 2,000 dermatologists, 459 responded. About half of the dermatologists (51%) routinely conduct potassium hydroxide mount (KOH) at the initiation of therapy. Similarly, about 53% of dermatologists initiate the management of dermatophytosis with combination therapy in all types of dermatophytosis for 4-6 weeks depending upon severity. Different types of combinations are being practiced, such as either two systemic and one topical, two topicals and one systemic, but the combination of one systemic and one topical (69%) is the most commonly practiced. Itraconazole (100 mg twice a day) and luliconazole are the most commonly prescribed antifungal medications. In case of non-response to routine dose of systemic anti-fungals, about 72% of dermatologists up dose them. Most of them continue these drugs for additional 1-2 weeks after clearance of the disease. Additionally, keratolytics and moisturizers are commonly prescribed. Additionally, 62% advise liver function tests (LFTs) at the initiation of therapy, whereas 72% advise monitoring adverse effects due to systemic antifungal drugs during treatment.

Conclusion

Combination therapy stood out as the need of the hour in the current menace of dermatophytosis with timely monitoring of laboratory tests for adverse events due to the use of systemic antifungals for a longer duration.

P245 Arthrinium species, a filamentous ascomycetes isolated from samples of human cutaneous infections-report from a medical mycology laboratory of Assam, North-East India

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

 

Objectives

This study aims to report the isolation of closely related Arthrinium species from superficial skin lesions of five cases from a medical mycology laboratory of Assam, North East India.

Methods

The lesions were decontaminated with 70% ethanol and skin scrapings were collected on a sterilized glass plate. Direct mounts were prepared in 10%-20% KOH and cultures were put in Saboraud's Dextrose Agar with antibiotics, 5% sheep blood agar, and dermatophyte test medium (Himedia, India). Plates and tubes were incubated as per standard mycological techniques described. Molecular identification was done using ITS sequence analysis using ITS1 and ITS4 universal primers.

Results

Direct mount showed presence of hyphae with arthrospores in 3/5 cases. In one case, fungal hyphae was seen along with spore-like oval or round structures of about 3-4 μm diameter. Pure growth was seen after 7-14 days in multiple culture tubes in all five cases. Colonies were white, downy initially becoming white, and floccose on further incubation. Subculture on PDA in all the cases for 15-20 days revealed black, round, and oval spores of 3-5 μm suggesting Arthrinium spp.

The taxonomical identification was done by constructing a phylogenetic tree of the ITS sequences of the Arthrinium isolates of this study along with reference Arthrinium strains and Seiridium phylicae as the outgroup taxa.

The phylogenetic analysis clustered the isolates of this study into closely related Arthrinium species.

Conclusion

The genus Arthrinium belonging to the family Apiosporaceae, class Sordariomycetes which comprises of a group of filamentous ascomycetes fungi is rarely reported from human infections. We are reporting closely related Arthrinium spp from five cases of skin lesions from Assam, North East India. Three of the 5 cases hailed from tea garden areas of Assam. Arthrinium isolation in clinically significant cases and in multiple tubes may not be disregarded as a contaminant.

Hybrid conferences in the post-COVID-19 era: Time yet for a paradigm shift for medical associations

Since the first COVID-19 lockdown in India was declared, all scientific conferences and related activities have been conducted in online formats (1). The ACS(I) [Association of Cutaneous Surgeons (India)] conducted its Annual National Conference called ACSICON-2021 for over 1150 delegates in mid-2021 in a hybrid mode. ACS(I) was one of the first organizations to embrace the hybrid conferencing strategy in the post-COVID-19 era in India. However, while meeting feedback and testimonials are typically gathered, there is very little public data documenting conference attendees’ viewpoints. The goal of this research study was to look at the viewpoints of medical conference attendees (such as physicians and medical professionals) on hybrid conferencing as a future trend, the danger of infectivity and transmissibility of COVID-19 during and after the event, the effectiveness of stringent safety protocols and vaccination in preventing the disease and thereby assess the feasibility of hybrid conference as the most convenient mode of learning interaction in the current COVID-19 era and also Post COVID-19 era.

Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task Force against Recalcitrant Tinea (ITART) Consensus on the Management of Glabrous Tinea (INTACT)

Background and Aims:

Dermatophytosis has always been a common superficial mycosis in India. However, the past 6-7 years have seen an unprecedented increase in the number of patients affected by recurrent, chronic, recalcitrant and steroid modified dermatophytosis involving the glabrous skin (tinea corporis, tinea cruris and tinea faciei). Importantly, there has been a notable decrease in clinical responsiveness to commonly used antifungals given in conventional doses and durations resulting in difficult-to-treat infections. Considering that scientific data on the management of the current epidemic of dermatophytosis in India are inadequate, the Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task force Against Recalcitrant Tinea (ITART) has formulated a consensus statement on the management of dermatophytosis in India.

Methods:

Seventeen dermatologists with a focussed interest in dermatophytosis participated in a Delphi consensus method, conducted in three rounds. They responded as either “agree” or “disagree” to 132 statements prepared by the lead experts and gave their comments. Consensus was defined as an agreement of 80% or higher concurrence. Statements on which there was no consensus were modified based on the comments and were then recirculated. The results were finally analysed in a face-to-face meeting and the responses were further evaluated. A draft of the consensus was circulated among the participants and modified based on their inputs.

Results:

Consensus was achieved on 90 of the 132 statements. Direct microscopy using potassium hydroxide mount was recommended in case of diagnostic difficulty on clinical examination. Counselling of patients about strict adherence to general measures and compliance to treatment was strongly recommended as the key to successful management of dermatophytosis. A combination of systemic and topical antifungal drugs was recommended for the treatment of glabrous tinea in the current scenario. Topical corticosteroid use, whether used alone or in combination with other components, was strongly discouraged by all the experts. It was suggested that topical antifungals may be continued for 2 weeks beyond clinical resolution. Itraconazole and terbinafine were recommended to be used as the first line options in systemic therapy, whereas griseofulvin and fluconazole are alternatives. Terbinafine was agreed to be used as a first line systemic agent in treatment naïve and terbinafine naïve patients with glabrous tinea. Regular follow-up of patients to ensure compliance and monitoring of clinical response was recommended by the experts, both during treatment and for at least 4 weeks after apparent clinical cure. Longer duration of treatment was recommended for patients with chronic, recurrent and steroid modified dermatophytosis.

Conclusion:

Consensus in the management of dermatophytosis is necessary in the face of conventional regimens proving ineffective and dearth of clinical trials re-evaluating the role of available antifungals in the wake of evolving epidemiology of the infection in the country. It needs to be backed by more research to provide the required level of evidence. It is hoped that this consensus statement improves the quality of care for patients with dermatophytosis, which has emerged as a huge public health problem, imposing considerable financial burden on the country.

Recommendations for Cutaneous and Aesthetic Surgeries during COVID-19 Pandemic

Background:

Amid the coronavirus disease 2019 (COVID-19) pandemic, dermatologists must be prepared to restructure their practice of procedural dermatology and cutaneous aesthetic surgeries. The COVID-19 pandemic has presented several challenges and has ushered in several changes in practice such as teledermatology, with many physicians adopting virtual consultations and treatments. Performing procedures in the times of COVID-19 pandemic presents challenges such as risk of transmission to doctors and staff due to potential aerosolization, release of virus droplets during the procedures, and risk of virus transfer through the instruments both in the peri- and postoperative period. This can have several medical, administrative, and legal implications.

Objectives:

This document aimed to outline best practices that can be followed in this scenario to perform cutaneous surgeries and procedures to ensure safer skin surgery.

Recommendations:

Standard precautions include social distancing of at least 1 m, hand hygiene, appropriate use of personal protective equipment (PPE), safe injection practices, sterilization and disinfection of medical devices, environmental cleaning, and respiratory hygiene. It is generally advisable to see patients only by appointments. Each clinic should have a special area at entry for screening patients and providing sanitizers and masks. Procedures, which are of short duration, performed on nonfacial areas are considered as low risk and require donning surgical mask. Procedures involved with minimal invasiveness and bleeding, short duration procedures on the face such as injectables, chemical peels, and aerosol-generating procedures on nonfacial areas are considered moderate risk. These procedures need apron with head cover, N95 mask, face shield, double gloves, and smoke evacuator with high-efficiency particulate air (HEPA) or ultralow particulate air (ULPA) filter. Aerosol and plume-regenerating procedures (such as ablative lasers on the face), prolonged surgeries on head (such as hair transplantation), intraoral, and intranasal procedures are considered high risk. These procedures must be carried out with full body cover with surgical gown, head cover, N95 mask, face shield, double gloves, and smoke evacuator. Physicians should be aware of local epidemiological situation and adhere to the relevant guidelines issued by the relevant governmental agencies.

Abstract P3-05-08: Lymphoid and myeloid cell characterization of inflammatory breast cancer tumor microenvironment and correlation to pathological complete response

Background: Inflammatory breast cancer (IBC) is an aggressive form of breast cancer with poor response rates to current chemotherapy regimens. With recent successes of immune targeted therapies in other solid tumors and a growing understanding of how the immune tumor microenvironment (TME) affects non-IBC outcomes, we sought to characterize the immune TME in IBC to identify biomarkers of treatment response and potential targets for drug development.

Methods: Pre-treatment core biopsy samples were identified from the MD Anderson Cancer Center IBC tissue bank from patients with stage III and de novo stage IV (with T4d) disease who received neoadjuvant chemotherapy (NAC) with intent to take to mastectomy. Lymphocytes were characterized by stromal tumor infiltrating lymphocyte (sTIL) quantification, CD8 T cell quantification, and T cell receptor sequencing. PD-L1 expression was assessed using DAKO 22C3 clone on tumor and immune cells. Myeloid cells were characterized using a multiplex immunohistochemistry approach, using CD68 and CD163 for macrophage markers, tryptase for mast cell marker, HLA-DR for class II antigen presentation marker, and cytokeratin as tumor marker. Spatial analyses were performed by determining probabilities of finding cell 1 of interest within 20 uM of cell 2 of interest and computing area under the curve for statistical comparison.

Results: 91 patients with stage III (N=62) or de novo stage IV (n=29) disease were identified. Breast cancer subtype included 25 triple negative, 34 HER2+ and 32 HER2-HR+. 86 patients received a mastectomy, of whom 33 (38.4%) patients experienced a pathologic complete response (pCR). sTIL was higher in stage III tumors (11.9 vs 4.8%, p&lt;0.001) and in those having a pCR (13.8 vs 7.3%, p=0.019). CD8 T cell density (available in 48 cases) similarly was higher in stage III patients (360.3 vs 178.8 counts/mm2, p=0.040) and pCR cases (452.3 vs 219.2 counts/mm2, p=0.080) but also higher in HER2+ disease (560.9 for HER2+ vs 239.9 counts/mm2, p=0.087 for TNBC and 153.6 counts/mm2, p=0.005 for HER2-HR+). T cell clonality (available in 32 cases) ranged from 0.004 to 0.242 but showed no correlation to tumor characteristics or response. PD-L1 complete tumor membranous expression was seen in only 1 of 47 cases, whereas PD-L1 positivity on immune cells was seen on 36.2% of cases; neither correlated to response. Myeloid cell assessment (available in 25 cases) showed higher mast cell infiltration in non-pCR cases (63.8 vs 26.8 counts/mm2, p=0.008) and spatial analysis (performed on 10 cases) identified that closer proximity of mast cells to CD8 T cells correlates with response (AUC 6.0 vs 2.2, p=0.017), suggesting a possible immunosuppressive mechanism. HLA-DR analysis demonstrated no difference by response as a single stain marker, but co-localization of HLA-DR with cell type shows higher HLA-DR expression on tumor cells in non-responders (14.6 vs 1.6%, p=0.031).

Conclusions: Higher TIL and CD8 T cell density are correlated with improved responses to NAC in IBC. Mast cell infiltration and HLA-DR expression on tumor cells are inversely correlated to response and suggest possible mechanisms of resistance. Mast cells could present potential therapeutic target in IBC.

Citation Format: Reddy SM, Reuben A, Jiang H, Roszik J, Tetzlaff MT, Reuben J, Wang L, Tsujikawa T, Barua S, Rao A, Villareal L, Wood A, Woodward W, Ueno NT, Krishnamurthy S, Wargo JA, Mittendorf EA. Lymphoid and myeloid cell characterization of inflammatory breast cancer tumor microenvironment and correlation to pathological complete response [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-05-08.

Milk-fat globule epidermal growth factor 8 (MFGE8) is expressed at the embryo– and fetal–maternal interface in equine pregnancy

Milk-fat globule epidermal growth factor (EGF) 8 protein (MFGE8), also known as lactadherin, promotes cell adhesion in an Arg-Gly-Asp (RGD)-dependent modus via integrins. In the present study, the expression of MFGE8 was examined in equine endometrium during oestrus and at Days 12 and 16 after ovulation in pregnant and non-pregnant mares and in mares during the 5th month of gestation. Results demonstrated that MFGE8 is expressed at the embryo– and fetal–maternal interface in equine pregnancy. In non-pregnant endometrium its expression was upregulated by oestrogen, a finding that was confirmed using endometrial explant culture. MFGE8 was expressed at similar levels by conceptuses collected 13 and 14 days after ovulation and by allantochorion sampled during the 5th month of gestation. Pericytes of endometrial blood vessels displayed strong MFGE8 expression upon in situ hybridisation. During the 5th month of gestation, the fetal side of the allantochorionic villi in particular displayed pronounced staining upon in situ hybridisation, confirming that MFGE8 expression is not restricted to early pregnancy but persists and is present at the fetal–maternal interface. Potential roles of MFGE8 in equine pregnancy include mediating cell–cell adhesion, promotion of angiogenesis and placental transfer of fatty acids.

Standard Guidelines of Care: Performing Procedures in Patients on or Recently Administered with Isotretinoin

BACKGROUND

Currently, the standard protocol regarding the performance of procedures on patients receiving or having recently received isotretinoin (13-cis-retinoic acid) states that the procedures should not be performed. The recommendations in standard books and drug insert require discontinuation of isotretinoin for 6 months before performing cosmetic procedures, including waxing, dermabrasion, chemical peels, laser procedures, or incisional and excisional cold-steel surgery. These recommendations have been followed for over two decades despite little evidence for the stated increased risk of scarring.

OBJECTIVE

The Association of Cutaneous Surgeons (I) constituted a task force to review the evidence and to recommend consensus guidelines regarding the safety of skin procedures, including resurfacing, energy-device treatments, and dermatosurgical procedures in patients with concurrent or recent isotretinoin administration.

MATERIALS AND METHODS

Data were extracted from the literature through a PubMed search using the keywords "isotretinoin," "safety," "scarring," "keloids," "hypertrophic scarring," and "pigmentation." The evidence was then labeled and circulated to all members of task force for review.

RESULTS

The task force is of the opinion that there is insufficient evidence to support the current protocol of avoiding and delaying treatments in the patient group under consideration and recommends that the current practice should be discontinued. The task force concludes that performing procedures such as laser hair removal, fractional lasers for aging and acne scarring, lasers for pigmented skin lesions, fractional radio-frequency microneedling, superficial and medium-depth peels, microdermabrasion, dermaroller, biopsies, radio-frequency ablation, and superficial excisions is safe in patients with concurrent or recent isotretinoin administration.

VULNERABILITY OF LOW-ARSENIC AQUIFERS TO MUNICIPAL PUMPING IN BANGLADESH

Sandy aquifers deposited >12,000 years ago, some as shallow as 30 m, have provided a reliable supply of low-arsenic (As) drinking water in rural Bangladesh. This study concerns the potential risk of contaminating these aquifers in areas surrounding the city of Dhaka where hydraulic heads in aquifers >150 m deep have dropped by 70 m in a few decades due to municipal pumping. Water levels measured continuously from 2012 to 2014 in 12 deep (>150m), 3 intermediate (90-150 m) and 6 shallow (<90 m) community wells, 1 shallow private well, and 1 river piezometer show that the resulting drawdown cone extends 15-35 km east of Dhaka. Water levels in 4 low-As community wells within the 62-147 m depth range closest to Dhaka were inaccessible by suction for up to a third of the year. Lateral hydraulic gradients in the deep aquifer system ranged from 1.7×10^-4 to 3.7×10^-4 indicating flow towards Dhaka throughout 2012-2014. Vertical recharge on the edge of the drawdown cone was estimated at 0.21±0.06 m/yr. The data suggest that continued municipal pumping in Dhaka could eventually contaminate some relatively shallow community wells.

Surgical Outcome in Patients Taking Concomitant or Recent Intake of Oral Isotretinoin: A Multicentric Study-ISO-AIMS Study

BACKGROUND

The current standard recommendation is to avoid surgical interventions in patients taking oral isotretinoin. However, this recommendation has been questioned in several recent publications.

AIM

To document the safety of cosmetic and surgical interventions, among patients receiving or recently received oral isotretinoin.

MATERIALS AND METHODS

Association of Cutaneous Surgeons, India, in May 2012, initiated this study, at 11 centers in different parts of India. The data of 183 cases were collected monthly, from June 2012 to May 2013. Of these 61 patients had stopped oral isotretinoin before surgery and 122 were concomitantly taking oral isotretinoin during the study period. In these 183 patients, a total of 504 interventions were performed. These included[1] 246 sessions of chemical peels such as glycolic acid, salicylic acid, trichloroacetic acid, and combination peels;[2] 158 sessions of lasers such as ablative fractional laser resurfacing with erbium-doped yttrium aluminum garnet and CO2, conventional full face CO2 laser resurfacing, laser-assisted hair reduction with long-pulsed neodymium-doped yttrium aluminum garnet, diode laser, and LASIK surgery;[3] 27 sessions of cold steel surgeries such as microneedling, skin biopsy, subcision, punch elevation of scars, excision of skin lesion, and wisdom tooth extraction;[4] 1 session of electrosurgery.

RESULTS

No significant side effects were noted in most patients. 2 cases of keloid were documented which amounted to 0.4% of side effects in 504 interventions, with a significant P value of 0.000. Reversible transient side effects were erythema in 10 interventions and hyperpigmentation in 15.

CONCLUSION

The study showed that performing dermatosurgical and laser procedures in patients receiving or recently received isotretinoin is safe, and the current guidelines of avoiding dermatosurgical and laser interventions in such patients taking isotretinoin need to be revised.

Is Lesional Stability in Vitiligo More Important Than Disease Stability for Performing Surgical Interventions? Results from a Multicentric Study

Background:

Ensuring stability of the disease process is essential for undertaking surgical intervention in vitiligo. However, there is no consensus regarding the minimum duration of stability or the relative importance of disease and lesional stability in selecting patients for vitiligo grafting.

Aim:

This multicentric study aims to assess the relative importance of lesional and disease stability on selecting patients for vitiligo grafting.

Materials and Methods:

One hundred seventy patients were recruited into the study and divided into two groups: Group A with lesional stability of >1 year but overall disease stability of only 6-11 months and Group B with overall disease stability of >1 year. Patients underwent either tissue or cellular vitiligo grafting on the selected lesions and the repigmentation achieved was scored from 0 (no repigmentation) to 6 (100% repigmentation). Repigmentation achieved on different sites of the body was compared between the two groups. Adverse effects at both the donor and the recipient sites were also compared.

Results:

Of the 170 patients who were enrolled, 82 patients were placed in Group A and 88 patients in Group B. Average repigmentation achieved (on scale of 0 to 6) was 3.8 and 4.04 in Group A and Group B, respectively. In Group A, ≥90% repigmentation was achieved in 36.6% (30/82) patients, while 37.5% (33/88) achieved similar results in Group B. Additionally, 47.6% (39/82) and 53.4% (47/88) of cases achieved partial repigmentation in Group A and Group B, respectively. Perigraft halo was the commonest adverse effect observed in both groups. Statistical analysis revealed no significant differences between the two groups with respect to the repigmentation achieved or adverse effects observed. Repigmentation achieved was the best on the face and neck area, while acral areas responded the least.

Conclusions:

Lesional stability seems to be as relevant as the overall disease stability in selecting patients for surgical intervention in vitiligo.

Laser-tissue interaction in tattoo removal by q-switched lasers

Q-switched (QS) lasers are widely considered the gold standard for tattoo removal, with excellent clinical results, impressive predictability, and a good safety profile. The generation of giant pulses by the method of Q-switching is responsible for the unique laser-tissue interaction that is seen in tattoo removal by QS lasers. The QS lasers work by impaction and dissolution of the tattoo pigments. Mechanical fragmentation of the tattoo pigments encased in intracellular lamellated organelles followed by their phagocytosis by macrophages is thought to be the major event in the clearance of pigments by QS lasers. A few novel techniques have been tried in recent times to hasten the clearance of tattoo pigments.

Elevated arsenic and manganese in groundwaters of Murshidabad, West Bengal, India

High levels of geogenic arsenic (As) and manganese (Mn) in drinking water has led to widespread health problems for the population of West Bengal, India. Here we delineate the extent of occurrences of As and Mn in Murshidabad, where the contaminated aquifers occur at shallow depths between 35 and 40 m and where access to safe drinking water is a critical issue for the local population. A total of 78 well-water samples were taken in 4 blocks on either side of the river Bhagirathi: Nabagram and Kandi (west, Pleistocene sediments), Hariharpara and Beldanga (east, Holocene sediments). High As, total iron (FeT) and low Mn concentrations were found in waters from the Holocene gray sediment aquifers east of the river Bhagirathi, while the opposite was found in the Pleistocene reddish-brown aquifer west of the river Bhagirathi in Murshidabad. Speciation of As in water samples from Holocene sediments revealed the dominant species to be As(III), with ratios of As(III):AsT ranging from 0.55 to 0.98 (average 0.74). There were indications from saturation index estimations that Mn solubility is limited by the precipitation of MnCO3. Tubewells from high As areas in proximity to anthropogenic waste influx sources showing high molar Cl/Br ratios, low SO4(2-) and low NO3(-) demonstrate relatively lower As concentrations, thereby reducing As pollution in those wells. Analyses of core samples (2 in each of the blocks) drilled to a depth of 45 m indicate that there is no significant variation in bulk As (5-20mg/kg) between the Holocene and Pleistocene sediments, indicating that favorable subsurface redox conditions conducive to mobilization are responsible for the release of As. The same applies to Mn, but concentrations vary more widely (20-2000 mg/kg). Sequential extraction of Holocene sediments showed As to be associated with 'specifically sorbed-phosphate-extractable' phases (10-15%) and with 'amorphous and well crystalline Fe-oxyhydroxide' phases (around 37%) at As-contaminated well depths, suggesting that the main As release mechanisms could be either competitive ion exchange with PO4(3-), or the dissolution of Fe oxyhydroxides. In the Pleistocene sediments Mn is predominantly found in the easily exchangeable fraction.

Genetic Analysis of the Neuraminidase (NA) Gene of Equine Influenza Virus (H3N8) from Epizootic of 2008-2009 in India

The neuraminidase (NA) gene sequences of four Indian equine influenza viruses (EIVs) isolated from epizootic in 2008 and 2009 were analyzed. The phylogenetic relationship and selection pressure of NA genes were established in comparison to other EIVs circulating worldwide along with the domains and motifs of the encoded protein to find out the significance of mutational changes. Among Indian isolates, two amino acid (aa) changes each in Mysore/12/08 (Asn67Tyr & Asp396Gly), Gopeshwar/1/09 (Ile49Val & Asp396Gly), and Uttarkashi/1/09 (Ile49Val & Asp396Gly) isolates were observed in respect to Jammu-Katra/06/08 isolate. Amino acid (aa) sequence analysis also revealed five consistent aa residue changes viz, Gly/Arg40Glu, Tyr66His, Val191Ile, Val209Ile and Asp235Asn in Asian including Indian isolates, Spain/07 and Spain/09 isolates in comparison to other EIVs circulating worldwide. The topology of the phylogenetic tree revealed that the Indian, Chinese, Mongolian and Kazakhstan isolates together formed a subgroup with Yokohama/10 isolate. Spain/07 & Spain/09 isolates showed closest clustering with Asian isolates. This indicates that non-synonymous mutations in Asian isolates with temporal pattern originating from Spain/07, led to the subgroup of the Asian isolates within Florida clade 2 sublineage. The analysis of the predicted secondary structure has not shown any significant difference in the NA proteins of all Indian isolates. Fixed-effects likelihood (FEL) analysis of the selection pressure revealed three codons (43, 355 & 434) under positive selection pressure. The overall evolutionary changes (ω value) of 3.4 indicates NA gene to be under strong selection pressure. Further, seven putative N-glycosylation sites were observed in the NA protein. The mapping of specific aa changes, their mutational and functional analysis need to be carried out to ascertain their role in pathogenecity of the virus.

Anti-inflammatory effect of low intensity ultrasound (LIUS) on complete Freund's adjuvant-induced arthritis synovium

OBJECTIVES

Arthritis with intra-articular inflammation was accompanied by joint pain, swelling, and stiffness leading to significant functional impairment. Thus, regulation of joint inflammation is a good therapeutic approach for patients with arthritis. In this study, the effect of low intensity ultrasound (LIUS) applied to an adjuvant-induced arthritic rat model on the synovium was investigated.

DESIGN

Synovial inflammation was induced by complete Freund's adjuvant (CFA)-injection into the rat knee joint. LIUS (200 mW/cm(2)) was applied on the ipsilateral knee everyday for 10 min beginning 1 day after inflammation induction. The expression of proinflammatory factors and immunohistochemical staining pattern of the synovium were assessed.

RESULTS

CFA induced an increase of the knee circumference that was significantly diminished by LIUS. Synovial membrane hyperplasia in the ipsilateral joint was also affected by LIUS. The inflammatory mediators, COX-1/2, IL-1β, and iNOS, but not TNF-α, in the synovial membrane were induced after 3 days, and they closely correlated with the degree of edema. In the synovial membrane, the expression of inflammatory mediators was reduced by LIUS. The chemoattractant chemokine receptor CCR5 also was involved. On immunohistochemical analysis, CFA caused increased infiltration of CD11b-positive cells in the synovium. After 3 days, neutrophils, myeloperoxidase (MPO)-positive cells filled the inflammatory core; later, monocytes and macrophages, ionized calcium binding adaptor molecule 1 (Iba1)-positive cells in the periphery infiltrated the core by day 5. LIUS markedly reduced CFA-induced inflammatory cells infiltration.

CONCLUSION

LIUS showed a potent anti-inflammatory effect in this animal arthritis model with reduced infiltration of inflammatory cells into the synovium.

Elimination of neglected tropical diseases in the South-East Asia Region of the World Health Organization

The neglected tropical diseases (NTDs), which affect the very poor, pose a major public health problem in the South-East Asia Region of the World Health Organization (WHO). Although more than a dozen NTDs affect the region, over the past five years four of them in particular - leprosy, lymphatic filariasis, visceral leishmaniasis (kala-azar) and yaws - have been targeted for elimination. These four were selected for a number of reasons. First, they affect the WHO South-East Asia Region disproportionately. For example, every year around 67% of all new leprosy cases and 60% of all new cases of visceral leishmaniasis worldwide occur in countries of the region, where as many as 850 million inhabitants are at risk of contracting lymphatic filariasis. In addition, several epidemiological, technological and historical factors that are unique to the region make each of these four diseases amenable to elimination. Safe and effective tools and interventions to achieve these targets are available and concerted efforts to scale them up, singly or in an integrated manner, are likely to lead to success. The World Health Assembly and the WHO Regional Committee, through a series of resolutions, have already expressed regional and global commitments for the elimination of these diseases as public health problems. Such action is expected to have a quick and dramatic impact on poverty reduction and to contribute to the achievement of the Millennium Development Goals. This paper reviews the policy rationale for disease control in the WHO South-East Asia Region, the progress made so far, the lessons learnt along the way, and the remaining challenges and opportunities.

A peculiar case of HIV transmission within a family in north India

SUMMARY

We describe an unusual case of heterosexual HIV transmission between two brothers within a family, due to a locally prevalent social custom of remarriage of the elder brother's widow, to the younger brother. This case of HIV secondary transmission, which could possibly have been stopped at certain points by better understanding and awareness about HIV transmission emphasizes the need for extensive post-test counselling of affected individuals and their family members.

Onychomycosis by Scytalidium dimidiatum in green tea leaf pluckers: report of two cases

Two cases of onychomycosis in green tea leaf pluckers caused by Scytalidium dimidiatum, a dematiaceous non-dermatophytic mold has been described. Onychomycosis caused by Scytalidium dimidiatum is clinically indistinguishable from that caused by dermatophytes and responds poorly to antifungals. The clinical presentations in the cases were of distal subungual type with associated melanonychia involving thumbnails. These cases have unique importance, because besides disfigurement, this has adversely affected the livelihood of the patient and poor response to antifungal dissuaded them from treatment compliance. To the best of our knowledge, this is the first report of onychomycosis caused by Scytalidium dimidiatum in green tea leaf pluckers.

Maternal and newborn-care practices during pregnancy, childbirth, and the postnatal period: a comparison in three rural districts in Bangladesh

The aim of this study was to examine the prevalence of maternal and newborn-care practices among women reporting a birth in the previous year in three districts in different divisions of Bangladesh. In 2003, 6,785 women, who had delivered a newborn infant in the previous year, across three districts in Bangladesh, were interviewed. Overall, less than half of the women received any antenatal care, and 11% received a minimum of four check-ups. Only 18% took iron tablets for at least four months during pregnancy. Over 90% of the 6,785 deliveries took place at home, and only 11% were attended either by a doctor or by a nurse. The mothers reported three key hygienic practices in 54% of deliveries: attendants washing their hands with soap and boiling cord-tie and blade for cutting the cord. Forty-four percent of the 6,785 infants were bathed immediately after delivery, and 42% were given colostrum as their first food. The results suggest that maternal and newborn-care remains a cause of concern in rural Bangladesh. Short-term policies to promote healthy behaviour in the home are needed, in addition to the long-term goal of skilled birth attendance.