Paediatric Dermatology

Genetics of Vascular Malformations: Current Perspectives Kin Fon Leong Indian Journal of Paediatric Dermatology 2021 22(1):1-11 For decades, vascular anomalies are categorized as either vascular tumors or malformations based on their onset, clinical course, radiologic, and histologic features. Owing to the heterogeneity of vascular anomalies, they are frequently misdiagnosed. With the advent of massively parallel next-generation sequencing, the molecular landscape of vascular anomalies is rapidly evolving and recent discoveries have shed light on the genetic basis and classification of these vascular disorders. The genotype-phenotype correlation will provide a more precise classification of vascular anomalies and form the basis for future targeted pharmacologic therapy. Thus far, inhibitor of mTOR, AKT1, and PIK3CA (sirolimus, miransertib, and alpelisib) have promising clinical results. In vascular malformations, majority of sporadic cases are due to somatic mutations that disrupt the main endothelial receptor intracellular signaling pathways, i.e., PIK3CA-AKT-mTOR, RAS - MAPK – ERK, and SMAD signaling pathways. Most of the sporadic vascular malformations are caused by somatic mutations that are acquired after fertilization, instead of being inherited from his parents. In general, this type of mosaicism is not inherited, except when the mutation affects the gonads.

Cosmetic Procedures in Adolescents: What's Safe and What Can Wait Indian Journal of Paediatric Dermatology 2021 22(1):12-20 Teenagers between 13 and 19 years are increasingly seeking cosmetic procedures. They are suffering from anxiety, depression, and low self-esteem as a result of an obsession with body image and celebrity culture, fueled by social networking sites. Teenagers seek cosmetic procedures most commonly for traumatic scars, acne and acne scars, pigmentary abnormalities, hypertrichosis, hirsutism, and tattoo removal. They demand plastic surgery for nose deformities, breast asymmetry, ear abnormalities, and congenital deformities. The physical, emotional, psychological, social, ethical, and legal aspects must be considered while counseling adolescents. Not every teenager seeking cosmetic surgery is well suited for a procedure, and teens must demonstrate emotional maturity and an understanding of the limitations of these procedures and the risks involved. There should be a 3-month cooling-off period, followed by another consultation, which should be done in the presence of a parent. Only very essential surgery should be performed, giving realistic expectations on the outcome of procedures, as they rely too much on physical appearance to gain confidence. A psychiatric evaluation is essential to rule out body dysmorphic disorders in those repeatedly seeking treatment for minor defects. Sometimes, procedures are necessary to avoid social withdrawal and loss of self-esteem. Proper informed consent should be taken, explaining the benefits, limitations, and risks involved. Ideally, teenagers should not receive cosmetic or surgical procedures unless there are compelling medical or psychological reasons to do so. A successful aesthetic procedure in a mature teenager can have a positive influence, whereas surgery on an immature, psychologically unstable adolescent can have an adverse impact. This review discusses what is safe and what can wait, still there is limited evidence. There is a strong need for guidelines for the use of cosmetic surgery on children and teenagers.

Role of Elimination Diet in Atopic Dermatitis: Current Evidence and Understanding Indian Journal of Paediatric Dermatology 2021 22(1):21-28 Atopic dermatitis (AD) is a fairly common dermatosis of childhood. In many cases, parents are concerned that food allergy plays a role in their child's symptoms and they ask whether practicing elimination diets would help in controlling the symptoms. In this review, we try to provide concise answers to the questions raised by the parents, apart from addressing the myths associated with elimination diets in AD and provide scientific evidence in favor of or against the common notions. A comprehensive English-language literature search for the role of elimination diet in AD across multiple databases (PubMed, EMBASE, MEDLINE, and Cochrane) for keywords (alone and in combination) was performed. MeSH as well as non-MeSH terms such as “AD,” “diet elimination,” “treatment,” “prevention,” “evidence,” “blanket elimination,” and “specific exclusion diet” were taken into consideration. There is level I evidence to support specific exclusion diets in preselected and screened patients, but there is insufficient evidence to recommend strict (blanket) elimination diets.

Pattern of Dermatoses in Small Children in a Tertiary Care Hospital Indian Journal of Paediatric Dermatology 2021 22(1):29-36 Aims: The aim of the study was to study the pattern of dermatoses in children up to 5 years of age. Settings and Design: It is an observational study done in a tertiary care hospital. Subjects and Methods: A total of 505 patients, aged up to 5 years, attending the department of dermatology, venereology, and leprosy for a duration of 18 months from January 2017 to June 2018 were included in the study. Statistical Analysis Used: All results were statistically analyzed by IBM SPSS software and Chi-square test was used to compare the associations. Results: Preschoolchildren (75.44%) formed the majority. Males (54.65%) outnumbered females. Infections constituted the most (45.94%) followed by eczema (21.98%), hypersensitivity disorders (14.25%), nevi (4.55%), papulosquamous (3.76%), pigmentary (3.76%), physiological and transient noninfective neonatal conditions (3.56%), sweat gland (2.97%), hair disorders (0.59%), and other dermatoses (2.97%). Conclusions: Infections/infestations constituted the most among the dermatoses in children up to 5 years of age. As they are preventable, educating the parents, guardian, care takers, and teachers in the preschool about communicable diseases can limit their transmission and improve the well-being of children.

Clinical Spectrum of Cutaneous Adverse Drug Reactions in Pediatric Population in East Coast of Andhra Pradesh: An Observational Study VV V Satyanarayana, Suruthi Purushothaman, Bonu Chandipriya Indian Journal of Paediatric Dermatology 2021 22(1):37-42 Context: Cutaneous adverse drug reaction (CADR) among pediatric population is underappreciated and often misdiagnosed in clinical settings. Furthermore, epidemiologic data on only cutaneous adverse reactions among this population are limited. Aim: The aim of this study is to analyze the CADRs with reference to the pattern, causative drugs, its subgroup analysis, and other clinical characteristics among children. Settings and Design: This was an observational, hospital-based study over a period of 12 months. Materials and Methods: The CADRs occurring and referred to the inpatient and outpatient department of dermatology were actively monitored and the collected reports were analyzed for CADR pattern, drug groups, clinicodemographic profile, and severity of adverse drug reaction (ADR). Statistical Analysis Used: Data were documented in Microsoft Excel and analyzed using SPSS Version 20.0. Results: A total of 33 CADRs were documented. Most of the ADRs (40%) occurred between the age of 11 and 15 years. Antimicrobials comprised the major group of drugs causing ADRs (42.4%). Maculopapular rash (54.5%) and urticaria (15.2%) were the most common type of ADR. A single case of death due to anticonvulsant-induced toxic epidermal necrolysis had been observed in the study period. There were more occurrences of ADRs with multiple drugs compared to single-drug therapy. About 80% of reactions were of mild to moderate. Conclusion: Knowledge of the pattern and the offending drug helps in better diagnosis, management, reduced complications in this population, and also helps in preventing recurrences, thereby helps in promoting the safe use of drugs, which can overall impact the quality of health care among children positively.

Acne Fulminans: A Case Report and Review of Literature Indian Journal of Paediatric Dermatology 2021 22(1):43-47 Acne fulminans (AF), a variant of acne vulgaris, is a rare disease that occurs after treatment of AF with oral isotretinoin. Less than 200 cases of AF have been reported in literature, mostly in young men and all with varying clinical presentations. A thorough search of literature was performed for AF using PubMed, MEDLINE, EMBASE, and UK PubMed Central electronic databases. Pathogenesis is not clearly established. However, it is most likely due to hypersensitivity reactions to sebum or bacterial antigens. It presents as sudden eruption of friable, hemorrhagic crusting overlying the ulcers, plaques, and tender nodules, usually on the trunk, with or without systemic symptoms such as malaise, fever, and arthralgia a few days after initiation of oral isotretinoin therapy. Laboratory abnormalities including raised erythrocyte sedimentation rate, altered hematological profile, and radiological evidence of osteolytic bone lesions may be found. Treatment involves the use of oral steroids with subsequent addition of oral isotretinoin. Many other immunosuppressive therapies have been tried.

Clinical and Dermoscopic Spectrum: Novel Findings in Interesting Cases Indian Journal of Paediatric Dermatology 2021 22(1):48-51 Uncommon, interesting clinical entities presenting in dermatological practice often challenges the diagnostic skills of a trained dermatologist. A non-invasive tool for recognition of these conditions is especially relevant in the paediatric population and dermoscopy plays a pivotal role in diagnosing these cases. A spectrum of novel clinical and dermoscopic findings is reported in four interesting cases. (vitiligo ponctue, cutaneous larva migrans, zosteriform angiokeratoma, linear milia en plaque).

Norwegian (Crusted) Scabies Involving Eyelids and Conjunctiva Indian Journal of Paediatric Dermatology 2021 22(1):52-55 Scabies is a parasitosis caused by the mite sarcoptes scabiei var. hominis, with crusted scabies being more contagious than classic scabies because of a larger mite burden. It can lead to an epidemic of classic scabies if not diagnosed early and treated accordingly. We report a 10-year-old boy who presented with a complaint of an inability to open his left eye and irritation in the right eye. Examination showed the presence of multiple crusted lesions throughout the body, including face and eyelids, and a yellowish patch in the right bulbar conjunctiva. The histopathological evaluation of the specimen of the conjunctival lesion confirmed it to be sarcoptes infestation. Face and eyelids involvement are very rarely in crusted scabies and only a few cases have been reported in the past. Our report demonstrates conjunctiva as an unusual site of involvement in these cases.

Localized Pseudoxanthomatous Mastocytosis of Vulva Indian Journal of Paediatric Dermatology 2021 22(1):56-58 Cutaneous mastocytosis (CM) is a mast cell proliferative disorder that is common in the pediatric age group. Common entities are urticaria pigmentosa, solitary mastocytoma, telangiectasia macularis eruptive perstans. and diffuse CM. Pseudoxanthomatous mastocytosis presents in the form of yellowish nodular lesion resembling xanthoma and is a rare variant and not reported much in the literature. We, hereby report a rare case of localized vulvar pseudoxanthomatous mastocytosis in a 10-year-old female child.

Curious Subcutaneous Swellings: A Case of Pediatric Myocysticercosis Indian Journal of Paediatric Dermatology 2021 22(1):59-61 Cysticercosis is a parasitic infection caused by the larval stage of the tape worm, Cysticercus cellulosae, chiefly affecting the subcutaneous tissue, central nervous system, orbit, and the skeletal muscles. It occurs in human due to ingestion of contaminated water or raw meat of pig. We hereby present a case of a 6-year-old female presenting with multiple subcutaneous swellings of 3 months' duration, associated with painful movement and associated with a history of on and off fever and malaise. Local part ultrasonography revealed multiple cystic lesions in the muscular plane, with peripheral streak of calcification indicative of scolex. Fine-needle aspiration cytology of the lesions showed revealed degenerated and viable polymorphs, macrophages, few lymphocytes, and foreign body giant cells with foci of necrosis, with occasional hooklets of parasite, with findings suggestive of parasitic infection in neck with acute on chronic inflammation. Computed tomography (CT) scan of brain was normal. Thus, clinical, radiological, and cytological findings confirmed the diagnosis of myocysticercosis. This case is presented because of the rareness of its occurrence.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Dermatology

High prevalence of high-risk cutaneous squamous cell carcinoma in the thrace region of Turkey Sezgi Sarikaya Solak, Haydar Yöndem, Yildiz Gursel Urun, Mert Cezik, Nuray Can Turkish Journal of Dermatology 2020 14(4):83-89 Background: The characteristics of cutaneous squamous cell carcinoma (cSCC) may show differences according to the geographic distribution and ethnicity. Although most cSCCs are treated with surgical excision or other local interventions, high-risk cSCCs may have poor outcome. In the present study, we aimed to evaluate the clinicopathological characteristics and determine the high-risk features of cSCCs in the Thrace region of Turkey where the information on cSCCs is scarce. Methods: We retrospectively investigated the biopsy-proven cSCCs diagnosed between the years 2014 and 2018, in a tertiary university hospital and evaluated the high-risk features. Results: A total of 211 cSCCs were included. Men with cSCC were significantly younger than women with cSCC (P <.001). Almost one-half of the tumors (n = 103) were located on the lower lip. Patients with a cSCC on the lower lip were younger than those with a cSCC on the other sites. All patients with a cSCC on the ears were men. Twenty-eight percent of patients had tumor size more than 20 mm and 28% had tumor thickness more than 6 mm. Immunosuppression was present in 7.6% of patients. A total of 177 (83.9%) patients had high-risk cSCC. The local recurrence rate was 6.2%, and the metastasis rate was 5.2%. Conclusions: The Thrace region has significant number of cSCC, and high-risk features are very frequent. Clinicians should carefully evaluate the cSCCs in terms of high-risk features.

CYP4F22 gene mutations in patients with autosomal recessive congenital ichthyosis: Identification of two novel mutations Esra Arslan Ates, Hüseyin Onay, Ilgen Ertam, Esra Ataman, Filiz Hazan, Asude Durmaz, Tugrul Dereli, Ferda Özkinay Turkish Journal of Dermatology 2020 14(4):90-94 Background: Autosomal recessive congenital ichthyosis (ARCI) is a genetically heterogeneous keratinization disorder, which is clinically classified into five main forms: Lamellar ichthyosis, congenital ichthyosiform erythroderma, harlequin ichthyosis, self-healing collodion baby, and bathing suit ichthyosis. Mutations in TGM1, ABCA12, ALOX12B, ALOXE3, NIPAL4, CYP4F22, PNPLA1, LIPN, and CERS3 genes have been described in patients with ARCI. However, in 20% of the ARCI patients, the genetic defect remains unknown. Materials and Methods: In this study, we investigated the mutations in the CYP4F22 gene in ARCI patients who do not have mutations in two common ARCI genes, NIPAL4 and TGM1. Twenty-two patients diagnosed with ARCI and having no mutations in TGM1 and NIPAL4 genes were included in the study. Their CYP4F22 genes were sequenced using the Sanger sequencing method. Results: In 5 of 22 (22.7%) ARCI patients, four different mutations, of which two were previously reported, were found. The two novel mutations were c.976C> T and c.1189C> T. The c.727C> T and c.1303C>T mutations were previously reported. Conclusions: This study expands the CYP4F22 mutation spectrum and to provide more accurate genetic counseling for patients at risk.

Androphenotypic features in patients with coronary artery disease Gülsüm Gençoglan, Fatmagül Gülbaşaran, Işıl Inanir, Uğur Kemal Tezcan, Kamer Gündüz Turkish Journal of Dermatology 2020 14(4):95-98 Objective: It has been a debate whether phenotypic features are associated with increased risk of coronary heart disease. Proposed explanations for this relation include biological aging, individual susceptibilities, and androgens which contribute to both the atherosclerotic process and dermatological signs. The results of the studies are inconsistent and most are not based on cardiovascular imaging techniques. Here, association between androphenotypic features and the risk and severity of coronary artery disease (CAD) in men is evaluated. Methods: This case–control study consists of 166 male patients with angiography-proven CAD and 160 age-gender-matched controls. Gensini score of angiograms (for severity of CAD) and phenotypic characteristics including androgenetic alopecia (AGA), thoracic hairiness (TH), hair graying a diagonal earlobe crease (DEC), and hairy ear (HE) were recorded. Men with well-established cardiovascular risk factors were excluded. Results: AGA, DEC, and HE were significantly more frequent in patients with CAD than controls (98.2% and 83.1% [P < 0.001], 61.4% and 23.8% [P < 0.001], 69.3% and 50.6% [P = 0.001], respectively). As the severity of AGA increased, the incidence of heart disease was increasing in patients. The presence of TH and AGA was found to be related to higher Gensini scores. Conclusion: The exact mechanism between these phenotypic features and CAD still remains to be elucidated. However, observation of visible aging signs is easy and inexpensive. AGA, HE, and DEC may be used as early screening tools for CAD.

Misleading clinical presentation of a palmar lichen nitidus masquerading as pompholyx Ghazal Ahmed, Satyaki Ganguly, Hitesh Yadav Turkish Journal of Dermatology 2020 14(4):99-101 Lichen nitidus is usually a chronic localized disease of unknown etiology having multiple differentials. A 10-year-old boy presented with itchy, multiple, discrete, grouped, and minute papules with surrounding erythema in some and exfoliation in few others, involving the center of the right palm, the palmar aspect of the left little finger with few lesions over the dorsal surface of both the hands. The presenting feature misguided us with a few clinical points which are unusual in lichen nitidus. We report the case to highlight the clinical mimicry and limitations of clinical assessment for diagnosing lichen nitidus.

Psoriasis vulgaris developing in healed pemphigus vulgaris: A rare case of epitope spread or isotopic response? Ravindranath Brahmadeo Chavan, Vasudha A Belgaumkar, Nitika Sanjay Deshmukh, Ranjitha Krishnegowda Turkish Journal of Dermatology 2020 14(4):102-105 Although psoriasis and autoimmune blistering diseases are considered to be disorders with completely different etiopathogenesis, literature has documented a few cases of psoriasis associated with bullous diseases, particularly bullous pemphigoid. Here, we report the case of a 30-year-old male presenting with multiple flaccid blisters and erosions, clinically and histopathologically consistent with the diagnosis of pemphigus vulgaris. Although all these lesions resolved after two doses of dexamethasone cyclophosphamide pulse therapy, he returned 3 weeks later with multiple erythematous scaly plaques developing over the postinflammatory areas, compatible with the diagnosis of psoriasis vulgaris, which necessitated a modification in the treatment protocol. This rare case highlights the diagnostic and therapeutic challenges accompanying this unique scenario and attempts to elucidate the probable pathogenic mechanisms underlying the co-existence (simultaneous or sequential) of these two apparently unrelated dermatoses.

Phacomatosis pigmentokeratotica associated with unilateral toe walking due to short achilles tendon Andac Salman, Ayse Deniz Yucelten, Ozlem Akin Cakici, Olcay Unver Turkish Journal of Dermatology 2020 14(4):106-108 Phacomatosis pigmentokeratotica (PPK) is characterized by the co-occurrence of speckled lentiginous nevus (nevus spilus) and an organoid nevus with or without extracutaneous involvement. The extracutaneous manifestations may vary widely with musculoskeletal, neurologic, ocular, and vascular findings. The PPK is also associated with an increased risk of cutaneous or extracutaneous tumors. Therefore, the patients with PPK should be followed up regularly for possible malignant transformation. Here, we report a 5-year-old boy with PPK associated with toe walking due to short Achilles tendon, which was not previously reported, to our knowledge.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Pulmonology

Chronic obstructive pulmonary disease: A review about gender differences Carolina Santos, Tiago Pereira, Raquel Barros Eurasian Journal of Pulmonology 2020 22(3):135-143 The major risk factor for chronic obstructive pulmonary disease (COPD) is smoking. COPD is thought to be traditionally a male illness, but its prevalence in women is increasing because they are adopting lifestyle habits similar to men. A literature review of publications indexed in MEDLINE, Latindex, SciELO, and DOAJ databases was carried out. Were considered 44 articles with relevance to the topic addressed. The literature review aim was to characterize the gender susceptibility differences in COPD development as well as the changes that this disease may induce in the lung function. Through the present literature review, it was verified that there are multiple aspects that contribute to gender inequalities in COPD development. Among them are genetic predisposition, hormonal factors, tobacco smoke components metabolization, anatomical and physiological characteristics, bronchial hyperreactivity, and noxious agent's exposure. Gender differences in deleterious effects of tobacco smoke on lung function do not hold consensus, as there are authors reporting a greater lung functional decline in women even when less exposed to harmful substances, while others have found no differences in many of lung functional parameters. The studies analyzed were different regarding methodology and sample characteristics, which may contribute to results discrepancy obtained by the researchers. COPD affects men and women in increasingly similar proportions, so it is important to identify and characterize the particularities of tobacco smoke effects in both genders to improve the knowledge about the disease.

How are radiological, spirometric and quality of life measures related to each other in cases of bronchiectasis Burcu Arpinar Yigitbas, Celal Satici, Elif Yelda Niksarlıoğlu Eurasian Journal of Pulmonology 2020 22(3):144-152 Background: Radiological, spirometric, and quality-of-life (QoL) measures are essential parameters influencing the prognosis of patients with bronchiectasis (BE). However, to date, few studies have evaluated these measures together. OBJECTIVE: The study objective is to assess the relationships between high resolution computed tomography, spirometric and QoL scores considered in the steady and exacerbation states of BE. METHODS: We reviewed retrospectively patients who had been diagnosed with BE. Ninety-two cases were deemed eligible and completed the Short Form-36 (SF-36) and St George's Respiratory Questionnaire (SGRQ). A statistical assessment looking for correlations between HCRT, spirometry and QoL questionnaires was performed. Besides, factors for the modified Bhalla score (MBS) and clinical exacerbations were evaluated. RESULTS: İn the exacerbation state, patients' spirometric parameters and the domains of the SF-36 were even more strongly correlated with MBS, in particular, symptom duration, exacerbation and hospitalization rates in the previous year. Linear regression models for the steady and exacerbation state revealed SF-36 domains, forced expiratory volume in 1 s predicted and symptom duration were more related to MBS. In addition, the exacerbation rate was related to the domains of the SF-36, MBS and hospitalization within the previous year in both the steady and exacerbation state of BE. CONCLUSIONS: As a result of this study, SF-36, which is rarely used in clinical practice, has been demonstrated to be more correlated with radiological and pulmonary function test (PFT) scores than SGRQ. Assessing the patient's disease status can be performed more efficiently if MBS and SF-36 are combined with PFT.

Evaluation of paraoxonase-1 enzyme activity and oxidative stress relations in malignant mesothelioma cases Didem Turgut Cosan, Güntülü Ak, Emine Çolak, Aylin Dal, Çağrı Öner, Ahu Soyocak, Ertuğrul Çolak, Hasan Veysi Güneş, Muzaffer Metintaş Eurasian Journal of Pulmonology 2020 22(3):153-157 BACKGROUND: Malignant pleural mesothelioma (MPM) is the most common cancer in the pleura and highly aggressive with a very poor prognosis. Asbestos, known as a carcinogenic mineral with fiber structures, is the main cause of MPM formation. Exposure to asbestos causes an increase in reactive oxygen species, deficiency of antioxidant enzyme levels, and DNA damage. As a result of asbestos pathogenesis, all of these changes cause pulmonary fibrosis, pleural diseases, and malignancies. The endogenous antioxidant paraoxonase-1 (PON-1) is a calcium-dependent esterase involved in the hydrolysis of lipid peroxides, and PON-1 has been shown to have protective properties in oxidative stress and inflammatory diseases in various studies. OBJECTIVE: The study aimed to examine the relationship of MPM with PON-1 enzyme activity and oxidative status using total oxidant status (TOS) and total antioxidant status (TAS). MATERIALS AND METHODS: The study population was formed of 33 retrospectively examined mesothelioma patients as MPM group and 33 age- and sex-matched healthy individuals as controls. PON-1 activity was measured spectrophotometrically by enzyme-linked immunosorbent assay method. Total antioxidant and oxidant status was determined using Rel Assay Diagnostics kit. Oxidative stress index (OSI) was estimated as the ratio of the TOS to the TAS levels. RESULTS: In the present study, PON-1, TOS, TAS, and OSI levels were adjusted by comorbidity and smoking. The results indicated that TOS and OSI of MPM patients increased compared to healthy controls (P < 0.001 for both). The results also demonstrated the decrease of PON-1 activity and TAS in MPM cases (P < 0.001, for both). CONCLUSION: These results suggested that oxidative stress occurring as a result of inhalation of asbestos fibers may reduce the level of PON-1.

Antifibrotic treatment in patients with idiopathic pulmonary fibrosis: Our experience in 41 cases Berna Akıncı Ozyurek, Derya Yenibertiz, Aslıhan Gürün Kaya, Sertaç Büyükyaylacı Özden, Yurdanur Erdoğan Eurasian Journal of Pulmonology 2020 22(3):158-162 INTRODUCTION: It has been shown that antifibrotic agents (pirfenidone and nintedanib), used in the treatment of idiopathic pulmonary fibrosis (IPF) in recent years, decelerate the worsening of pulmonary function tests and the progression of the disease and also reduce the frequency of acute exacerbations and hospitalizations. In this study, we aimed to evaluate the results of antifibrotic treatment that we have been using since 2013 in our clinic. MATERIALS AND METHODS: Forty-one patients diagnosed as IPF between August 1, 2013, and February 1, 2019, in the eighth clinic of our hospital were included in this study. The information of the patients was obtained from the patient files. Data were analyzed by descriptive statistical methods, Kolmogorov–Smirnov test, and Wilcoxon test. RESULTS: Thirty-eight patients were male and three patients were female. The mean age was 65.6 ± 7.0 years. The diagnosis of 34 patients was made clinically and radiologically, and 7 patients were diagnosed pathologically. The longest usage time of antifibrotic drugs was 5.5 years in 2 patients, and the minimum usage time was 6 months in 2 patients. Thirty-four patients were using pirfenidone and seven patients were using nintedanib according to the data of their last visit. There was no significant difference between the baseline 6-min walk test results and the 6th-month, 1st-year, 2nd-year, 3rd-year, and 4th-year results. A significant decrease was determined in diffusing capacity of the lungs for carbon monoxide (DLCO) test results of the 6th month and 1st year compared to baseline (baseline: 63%, 6th month: 57%, and 1st year: 43%) (P < 0.05). There was no significant difference in DLCO test results of the 2nd, 3rd, and 4th year compared to baseline (P > 0.05). A significant decrease was determined in forced vital capacity (FVC) results of the 2nd year compared to baseline (68% and 59%, respectively) (P < 0.05). There was no significant difference in the FVC results of the 6th month, 1st year, 3rd year, and 4th year compared to baseline (P > 0.05). CONCLUSION: Similar to the literature, we have experienced that antifibrotic drugs decelerate the progression of the disease, reduce the risk of developing exacerbations, and are more tolerable in terms of side effect profile compared to the previous treatments.

Evaluation of the sleep quality of patients admitted to the internal medicine outpatient clinic İdris Kirhan, Fatih Üzer Eurasian Journal of Pulmonology 2020 22(3):163-168 AIM: This study aimed to determine the sleep quality and the factors affecting sleep quality in patients admitted to the internal medicine outpatient clinic. MATERIALS AND METHODS: The study was conducted between July 1, 2019, and July 15, 2019, with a face-to-face questionnaire administered to the patients who applied to the internal medicine outpatient clinic of Harran University. A descriptive questionnaire, Pittsburgh Sleep Quality Index (PSQI), and Epworth Sleepiness Scale (ESS) were used in the study. RESULTS: One-hundred and twelve (48.0%) male and 121 (51.9%) female patients with a mean age of 38.5 ± 16.3 years (18–86 years) were included in the study. The total PSQI mean was 4.9 ± 3.0 and the score range was 0–15. The rate of those with poor sleep quality was 48.9%. The mean score of ESS was 5.0 ± 3.6, and 12 (30%) patients admitted to the outpatient clinic experienced excessive sleepiness during the day. Gender of the participants (P = 0.800), income level (P = 0.113), the size of the house they were living in (P = 0.783), body mass index (BMI) (P = 0.491), and comorbid diseases (P = 0.803) did not affect the sleep quality; the number of people living in the same house affected the sleep quality (P < 0.001). It was found that those with a high BMI (≥30) had significantly worse sleep quality than those without. Sleep quality decreased as the number of people living at home decreased. CONCLUSION: We found that almost half of the patients admitted to the internal medicine outpatient clinic had poor sleep quality. We also found that as the number of people living in the same home decreases, sleep quality deteriorates.

Bronchodilator reversibility: What are the differences between asthma and chronic obstructive pulmonary disease? Raquel Barros, Patrícia Araújo, Cláudia Mourato, Khrytyna Budzac, Ana Sofia Oliveira, Cristina Bárbara Eurasian Journal of Pulmonology 2020 22(3):169-174 INTRODUCTION: Currently, the bronchodilator reversibility is not recommended to differentiate asthma from chronic obstructive pulmonary disease (COPD); however, physiopathological specificities of each disease contribute to the differences in response to the drug. OBJECTIVES: The objective of this study is to evaluate the differences in bronchodilator response between asthmatic and COPD patients and to determine which of the bronchodilation criteria have the best ability to detect the positive response in these patients. MATERIALS AND METHODS: This was a cross-sectional study. The sample included 104 patients with asthma or COPD who performed lung function tests between January and March 2018. The whole sample was analyzed according to postbronchodilator variation (Δ) of lung function parameters, and the postbronchodilator reversibility was characterized using a multiple bronchodilation criteria. The drug used in reversibility test was salbutamol. RESULTS: In this study, Δ forced-expiratory volume in the 1st s (ΔFEV1) and a Δ Raw was statistically higher in the group with asthma compared with the group with COPD. In the asthma group, the criteria ↓ functional residual capacity (FRC) ≥10%, ↓Raw ≥ 35%, ↑ forced expiratory flow between 25% and 75% of vital capacity (FEF25%–75%) ≥20% and ↑ FEV1 and / or ↑ forced vital capacity ≥12% and 200 mL were those that presented a greater capacity of detecting a positive response to bronchodilator. The criteria ↑ FEF25%–75%≥20% and ↓ FRC ≥ 10% were those that had the greater ability of detecting airway reversibility in COPD group. CONCLUSION: The analysis of postbronchodilator FEV1 and raw modifications as well as the using of a combination of multiple bronchodilation criteria contribute to a deeper characterization of bronchodilator reversibility in asthma and COPD.

Subclinical peripheral neuropathy in patients with chronic obstructive pulmonary disease without hypoxemia Hatice Yurtgun, Baykal Tülek, Hakan Ekmekçi, Fikret Kanat, Mecit Süerdem Eurasian Journal of Pulmonology 2020 22(3):175-179 AIM: The aim of the study was to determine the prevalence of subclinical peripheral neuropathy (PNP) in stable chronic obstructive pulmonary disease (COPD) patients without severe hypoxemia. MATERIALS AND METHODS: Fifty-six (52 men and 4 women) patients with COPD without severe hypoxemia, 25 healthy smokers, and 24 healthy nonsmokers were included in the study. The latency, amplitude, and velocity measurements of right and left median motor nerve, tibial motor nerve, peroneal motor nerve, median sensory nerve, sural sensory nerve, right ulnar motor nerve, and right ulnar sensory nerve were performed. RESULTS: A high proportion of PNP was detected in the COPD group compared to the smoker and nonsmoker control groups (41.1%, 36.0%, and 33.3%, respectively). However, the difference between the groups was not statistically significant (P = 0.784). However, some of the electrophysiological measurements were statistically significantly worse in the COPD group (P < 0.05). In the COPD group, a correlation was not detected between PNP and duration of COPD, age, body mass index, smoking status (pack/year), forced vital capacity %, forced expiratory volume in 1 s %, SO2, and C-reactive protein values (P > 0.05). CONCLUSION: The present study demonstrates that the PNP may be an extrapulmonary manifestation of COPD. The physician should be aware of the possibility of PNP in COPD patients without severe hypoxemia.

Isolated pulmonary artery vasculitis Meltem Agca, Bedrettin Yildizeli, Emine Bozkurtlar, Simge Yavuz, Tulin Sevim Eurasian Journal of Pulmonology 2020 22(3):180-183 We present a unique case of a 26-year-old woman, which first evaluated as sarcoma or thromboembolic events with their clinical and radiological similarities of the pulmonary artery but diagnosed as isolated pulmonary artery vasculitis after endarterectomy with the help of histopathological examinations. After the endarterectomy procedure, the other causes that may lead to vasculitis had been excluded. The patient had the immunosuppressive therapy after the procedure, and her control computerized tomography revealed that the lumen of the pulmonary artery was wide open. Isolated pulmonary artery vasculitis must be considered as a differential diagnosis when a filling defect of the pulmonary artery had been detected without other systemic findings.

A case of diffuse endobronchial metastasis of rectum carcinoma presenting with symptoms of diffuse airway obstruction and respiratory failure Serap Argun Baris, Ece Sahinoglu, Ilknur Basyigit Eurasian Journal of Pulmonology 2020 22(3):184-186 Endobronchial metastases of extra pulmonary tumors are rare. This report presents a case with diffuse endobronchial metastases with rectum carcinoma. A 63-year-old non-smoker female was admitted to our outpatient clinic with dyspnea and dry cough for two months. She had a history of rectum carcinoma and resection surgery eight months ago. On physical examination, wheezing was remarkable. There was patchy consolidation in both lung fields on chest x-ray. PET-CT revealed widespread nodules in pulmonary parenchyma which were consistent with rectal cancer metastasis. Bronchoscopy was performed and revealed extensive mucosal infiltration and multiple various sizes of polypoid lesions in the distal trachea and both main lobar bronchus. The histopathological evaluation reported as metastasis of rectum carcinoma. The oncological medical treatment regimen and radiotherapy was also planned. She admitted to emergency department with chest pain and progressive dyspnea 2 months after the diagnosis. Thorax CT demonstrated that increased metastatic peribronchial infiltrates, septal thickening and endobronchial polypoid lesions which was consisted with lymphangitic carsinomatosis and endobronchial metastasis. There was hypercapnic respiratory failure according to arterial blood gases analysis. She was intubated and admitted to the intensive care unit (ICU) and died in ICU on 7th day of admission. This case indicates that the possibility of endobronchial metastasis should be considered in a patient with underlying malignancy. If available bronchoscopic intervention should be planned not to let misdiagnosis.

Acute inhalation injury after marijuana use: A hidden cause Selen Karaoglanoglu, Emine Serap Yilmaz, Irem Karaman, Sevket Ozkaya Eurasian Journal of Pulmonology 2020 22(3):187-190 Marijuana is one of the most extensively smoking substance all around the world, although not common in our society. Its effects on lung are similar to tobacco, causing increased cough, sputum, hyperinflation, and rapid bronchodilatation following with possible airway obstruction. Chronic usage of marijuana may cause a variety of conditions such as bronchitis, large bullae formation, and pneumonia. Here, we report an uncommon case of hidden marijuana smoking causing acute inhalation injury. A 39-year-old male had consulted clinics with sudden onset of dyspnea, cough, and nausea. His chest X-ray and thorax computed tomography have revealed peripheral opacities with ground-glass infiltrations. After a detailed review of history, he was diagnosed with acute inhalation injury due to hidden marijuana smoking. As a conclusion, clinicians who encounter with individuals who have concurrent inhalation damage need to take a careful exposure history and should be alert for the possibilities of further complications and a worsening clinical picture.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Physiotherapists

Funding for physiotherapy research Akhoury Gourang Kumar Sinha Physiotherapy - The Journal of Indian Association of Physiotherapists 2020 14(2):61-63

Cross-cultural adaptation, translation, and psychometric properties of Gujarati version of physical activity questionnaire for older children Salvi S Shah, Shraddha J Diwan Physiotherapy - The Journal of Indian Association of Physiotherapists 2020 14(2):64-69 BACKGROUND: The Physical Activity Questionnaire for Older Children (PAQ-C) is a self-administered questionnaire to assess physical activity (PA) among older children, and it is available in English, Dutch, Malay, Spanish, Turkish, and Gujarati languages. Cross-cultural adaptation and robust research on psychometric properties arise the need for current research on the PAQ-C in Gujarati language (PAQ-C [G]). METHODS: The study was carried out in three phases: cultural adaptation and translation into the Gujarati language from English using the forward-backward-forward method, pilot study on 10 children to assess the comprehensibility of the prefinal version, and psychometric properties of the final version of the questionnaire. To ensure the face and content validity of the PAQ-C (G) group, a consensus method was used. Each item was examined by a group of experts having a mean experience of 22.11 years in different fields. Each item was analyzed for content, meaning, wording, format, ease of administration, and scoring. Each item was scored by an expert group as either rejected, accepted, or accepted with modification. The procedure was continued until 80% of consensus for all items. Finally, 20 children were asked to complete the PAQ-C (G) on two occasions 1 week apart to examine its test–retest reliability. RESULTS: The reliability coefficient using the average-measure intraclass correlation coefficient (ICC) total score of PAQ-C (G) was 0.82 which is a strong positive correlation. The test–retest between individual items shows that PAQ-C (G) had a moderate-to-strong correlation with ICC value between 0.78 and 0.91. The internal consistency reliability of PAQ-C (G) was α = 0.94 and α = 0.92 for assessments 1 and 2, respectively. CONCLUSION: PAQ-C (G) has a good face–content validity and test–retest reliability which can be used to measure PA among Gujarati speaking older schoolchildren.

A study on the effect of manual hyperinflation on oxygenation and hemodynamic parameters in mechanically ventilated patients after valve replacement surgery Srijani Banerjee, Anjali Suresh Physiotherapy - The Journal of Indian Association of Physiotherapists 2020 14(2):70-73 BACKGROUND: Valve replacement surgeries being a major surgery require general anesthesia. Patients are kept on mechanical ventilation postoperatively which can cause some major dysfunctions of the respiratory and circulatory systems of the human body. Manual hyperinflation (MHI) is a technique that provides a tidal volume greater than the baseline volume and produces a turbulent flow that brings benefits such as improvement of static compliance of the respiratory system, increased oxygenation, mobilization of secretions, and recruitment of collapsed areas of the lung. OBJECTIVES: The aim of this study was to compare the effectiveness of MHI in valve replacement patients on mechanical ventilation in terms of SpO2, heart rate (HR), respiratory rate (RR), blood pressure (BP), mean arterial pressure (MAP), and rate pressure product (RPP). MATERIALS AND METHODS: Thirty cardiothoracic intensive care unit patients who were intubated and mechanically ventilated after valve replacement surgery were given 3–4 MHI breaths with an O2 flow rate of 15 L/min for 6–8 sets or till secretions were heard. Means of the pretreatment and posttreatment values were calculated and compared by the paired t-test. Results: The results from the statistical analysis show that SpO2 remained almost same (P = 0.499). However, heart rate increased significantly (P = 0.048) after MHI. There was no adverse change in RPP (P = 0.409), but BP (P = 0.00 and 0.006), RR (P = 0.000), and MAP decreased significantly (P = 0.0005). CONCLUSION: The MHI technique seems to promote more improvement in hemodynamic parameters than in oxygenation.

Effect of early mobility in mechanically ventilated patients with myasthenia crisis on duration of mechanical ventilation and length of intensive care unit stay Rajeev Aggarwal, Shikha Chauhan, Madhuri Behari, Charu Gupta, Vandana Dua Physiotherapy - The Journal of Indian Association of Physiotherapists 2020 14(2):74-79 BACKGROUND: Myasthenia crisis (MC) requires mechanical ventilation (MV) which, if prolonged, may lead to multisystem complications. Early mobility, a potent modality, remains underutilized in critically ill patients with neuromuscular diseases. METHODOLOGY: A prospective, pretest–posttest control group study was conducted on thirty mechanically ventilated patients with MC in intensive care setup in a tertiary care teaching hospital. They were randomly divided into experimental group and control group. Both the groups received standard medical care, chest physiotherapy, range of motion exercises, and nursing care. In addition, the experimental group received strengthening exercises for extremities and progressive mobilization to sitting at bedside, standing, marching, and walking at bedside till the patients were transferred to ward. Duration of ventilation, length of intensive care unit (ICU) stay (LOS), and adverse events were recorded. Independent t-test was used to compare the difference between two groups. RESULTS: Out of thirty patients, 15 were randomly divided into each group using a sealed envelope method. One participant in experimental group and three in control group could not be weaned off and were tracheostomized at 3 weeks. An intent to treat analysis was done for duration of ventilation (n = 30). A total of 16 ± 4.32 exercise sessions were given in experimental group. Duration of ventilation (8.93 ± 3.95 vs. 13.31 ± 4.71 days; 95% confidence interval [CI] −7.63 to − 1.13, P = 0.011) and LOS (10.48 ± 2.47 vs. 14.26 ± 3.35 days; 95% CI − 6.22 to − 1.34, P = 0.004) were significantly lower in experimental group as compared to the control group. Relative risk reduction of failure to wean off or need for tracheostomy in early mobility group was 67%. Number needed to treat for the prevention of tracheostomy was 8. CONCLUSION: Early mobilization of mechanically ventilated MC patients is feasible and leads to decrease in the duration of MV, thereby decreasing the length of ICU stay.

Effect of home-based pelvic floor muscle training based on the severity of incontinence on quality of life in women with stress urinary incontinence Zarna Ronak Shah, Priyanshu V Rathod Physiotherapy - The Journal of Indian Association of Physiotherapists 2020 14(2):80-83 BACKGROUND: The women of our country are different than any other developed or developing country due to its cultural, economic, and religious scenario. It has been observed that though stress urinary incontinence (SUI) is prevalent, Indian women tend to hide it and accept it very easily as a part of aging or consequences of delivery. They suffer in silence compromising their quality of life (QOL). They start avoiding attending social functions and gatherings. Even during household chores or during their working hours, they have to feel embarrassed because of leakage episodes. Compromised QOL affects women in many ways such as psychological and social. There is a strong need to work on these areas and prepare a protocol of exercise for such women so that their QOL can be improved. AIM: The aim of the study was to evaluate the effect of pelvic floor muscle training (PFMT) based on the severity of incontinence on QOL in women with SUI. METHODOLOGY: Seventy-three participants were recruited for an experimental study. Each participant was given 6 weeks of home-based PFMT based on the severity of incontinence which was decided by the Incontinence Severity Index. Pre- and post data were analyzed using SPSS 21.0. The outcome measure was the Incontinence Impact Questionnaire-Short Form score. RESULTS: Wilcoxon test was used to compare the pre- and postdata for all the participants. Z = −6.86 with P < 0.001. CONCLUSIONS: The home-based PFMT of 6 weeks given here was effective in improving QOL in female with SUI.

Determination of physical fitness index and its relation with body mass index among physiotherapy students Richa Mahajan, Dolly Rawat Physiotherapy - The Journal of Indian Association of Physiotherapists 2020 14(2):84-88 BACKGROUND: The physiotherapy profession demands the therapist to engage in activities which require good amount of cardiorespiratory fitness. PURPOSE: The main aim of this study was to determine the physical fitness index (PFI) of the physiotherapy students using the Harvard step test and to examine the relationship between the body mass index (BMI) and physical fitness. METHODS: Two hundred and forty-two (males and females) physiotherapy students participated in this cross-sectional study. Descriptive data for age, gender, height, and weight were obtained, and BMI was calculated. PFI was measured using the Harvard step test. RESULTS: Physical fitness was observed as poor for 84.71%, low average for 14.05%, and high average for 1.24% physiotherapy students. None of the participants had good or excellent fitness. CONCLUSIONS: No correlation was found between BMI and physical fitness. Cardiorespiratory fitness of the physiotherapy students was found to be poor. Therefore, there is a need to motivate the students to achieve the optimal level of fitness levels. It is recommended that the students should engage in physical activities, and institutions should include the different physical activities in the curriculum.

Average heart rate recovery in marathon runners: An observational study Basavaraj Motimath, Merlin Rajan Physiotherapy - The Journal of Indian Association of Physiotherapists 2020 14(2):89-92 INTRODUCTION: Marathon is a long-distance race which causes enormous physical challenges to the body. The fitness status of the runner should be checked to overcome these challenges. However, it can be assessed using an easy diagnostic method of heart rate recovery (HRR) as it is inexpensive and readily accessible. Regular monitoring and documentation of the HRR can guide a runner in his training and health status. AIM: This study was done to check the average HRR postimmediately and after 2 min of race using radial palpatory method. METHODOLOGY: The present study was a cross-sectional, observational study conducted in Belagavi city. The participants of all genders aged 18 years and above were enrolled in the study. The sample size was open ended. Heart rate was assessed using radial palpatory method before and after the marathon running. RESULTS: At the end of marathon running, the pulse rate had rapidly increased with a mean of 129.40 ± 9.79. After 2 min of postrunning, there was a significant drop in the pulse rate of mean 106.32 ± 11.53. A drop of 23.08 ± 8.63 beats was seen when compared to postimmediate and after 2-min pulse rate. When the heart rate was compared between the prepulse and after 2 min, there was a mean difference of 33.66 beats. CONCLUSIONS: The study concluded that HRR after 2 min of the run was about 23.08 ± 8.63, but it was observed that the heart rate did not go to its pretest value.

Low back ache, disability, and quality of life in jewelry workers in Bhayandar and Mira road area of Mumbai: An observational study Vishakha Patil, Shweta Rathod, Rajashree Naik, Avinash de Sousa Physiotherapy - The Journal of Indian Association of Physiotherapists 2020 14(2):93-97 BACKGROUND: Low back pain (LBP) is a common condition in clinical practice and may be seen in certain occupations due to awkward sitting postures. Studies have revealed LBP as a common problem affecting the quality of life (QOL) and causing disability in certain occupational settings. OBJECTIVE: The current study was aimed to study the prevalence of LBP, disability, and QOL in jewelry workers. Disability and QOL would be compared across genders. METHODOLOGY: One hundred and ninety-five jewelry workers were the participants of the study and were assessed on certain sociodemographic parameters, and the Nordic Musculoskeletal Pain Questionnaire, Modified Oswestry Low Back Pain Disability Questionnaire, and the WHO QOL Questionnaire brief version were administered to those with LBP. The data were statistically analyzed and presented. RESULTS: One hundred and ninety-five individuals participated in the study. Eighty-two (42.05%) reported the symptom of low back ache. Thirty-one males (n = 68) (45.58%) and 51 females (n = 127) (40.15%) reported the symptom. On the MOLBPQ questionnaire, the disability levels between genders showed no significant difference statistically. A mild negative correlation for the psychological domain of QOL and disability (rho = 0.49, P = 0.001) was obtained. CONCLUSIONS: LBP is a commonly occurring problem in jewelry workers and must be addressed. Larger studies are needed to validate and corroborate the findings of the current study.

Cross-cultural adaptation, reliability, and validity of the Gujarati fear-avoidance components scale Dibyendunarayan Dhrubaprasad Bid, Randy Neblett, Thangamani Ramalingam Alagappan, Charmy J Patel, Karishma N Patel, Rinkal L Patel, Shama J Narola, Vyoma V Sailor Physiotherapy - The Journal of Indian Association of Physiotherapists 2020 14(2):98-107 BACKGROUND: The Fear-Avoidance Components Scale (FACS) is a relatively new patient-reported outcome measure to measure pain-related fear avoidance (FA). OBJECTIVES: The aim of this study was to translate and culturally adapt the FACS into the Gujarati language and to determine the test–retest reliability and cross-cultural validity of the FACS-G in Gujarati-speaking Indian patients. METHODS: Translation and cross-cultural adaptation of the original English version of the FACS were performed according to published guidelines. Test-item comprehension was verified in a group of 20 patients with chronic musculoskeletal pain disorders (CMPDs) with a written survey and cognitive debriefing interview. The content validity of the final version of the FACS-G was then ascertained from a survey of 30 health-care professionals. A cohort of 150 CMPD patients completed the FACS-G and other FA-related patient-reported outcome measures to determine internal consistency, test–retest reliability, agreement, minimal detectable change (MDC), and construct validity. RESULTS: In the opinion of the health-care professional panel, the content validity was very good. The internal consistency (Cronbach's α = 0.827) and test–retest reliability (intraclass correlation coefficient = 0.923 [95% confidence interval = 0.837–0.963]) were both excellent. The MDC was found to be 13.27 points (scale range = 0–100). The FACS-G correlated most strongly with the FA Beliefs Questionnaire-G (r = 0.705), which supports the concept of convergent validity. It showed a weaker association with the depressive symptom subset of the Patient Health Questionnaire (r = 0.461), which supports the concept of divergent validity. It correlated moderately with the Roland-Morris Disability Questionnaire-G (r = 0.615) and Numerical Pain Rating Scale score (r = 0.521; P < 0.01). CONCLUSION: The FACS-G showed strong psychometric properties, providing evidence of the conceptual equivalence with the original English version. The FACS-G appears to be a reliable instrument for measuring FA in Gujarati patients with CMPD.

Effectiveness of 4-week backward walking training program incorporated with rhythmic auditory cueing on spatial and temporal gait parameters and balance in subjects with hemiparesis: An experimental randomized control trial Jude D'souza, Sandhya Wasnik Physiotherapy - The Journal of Indian Association of Physiotherapists 2020 14(2):108-113 AIM: The aim of the study was to investigate the effectiveness of a 4-week backward walking training (BWT) program incorporated with rhythmic auditory cueing on spatial and temporal gait parameters and balance in subjects with hemiparesis. MATERIALS AND METHODS: This was a experimental randomized control trial and random allocation was done using chit method. The study was conducted in the physiotherapy department with required infrastructure of tertiary health-care center. Forty subjects (male/female) aged 18–60, in Brunnstrom recovery stage 3, 4, and 5, and diagnosed with hemiparesis from onset to 2 years' duration were included in the study. Each subject was assessed for stride length, step length (paretic and nonparetic), cadence, walking velocity, 3-meters (3-m) backward walk test, Dynamic Gait Index (DGI), and Berg's Balance Scale (BBS) at baseline and 4 weeks post intervention. In addition to conventional physiotherapy exercises, Group A, experimental (n = 20), underwent backward walking training with rhythmic auditory cueing using metronome and Group B, control (n = 20), underwent backward walking training without rhythmic auditory cueing for 4 weeks. RESULTS: Post 4 weeks of training, in the experimental group,cadence improved by 20%(5% in control group), walking velocity reduced by 15% (0.3% control group), 3-m BWT reduced by 32% (20% in the control group), DGI improved by 40% (20% control group), and BBS improved by 20% (12% in the control group). There was no statistically significant improvement in stride length and step length in both the groups. CONCLUSIONS: It is concluded that backward walking training incorporated with rhythmic auditory cueing and conventional physiotherapy exercises is effective in improving cadence, walking velocity, 3-m backward walk test, DGI, and BBS in stroke subjects.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Medical Genetics

Orodental abnormalities in limb malformation syndromes: A review article Nehal F Hassib, Eman A AbulEzz, Magda Ramzy, Tarek El-Badry, Mona S Aglan, Samia A Temtamy Middle East Journal of Medical Genetics 2020 9(1):1-9 The regular synchronization during development of an embryo results in the normal formation of his/her structures. The deviation from this harmony produces malformations. The pleiotropic effects of similar genes that contribute in the growth of limb and oral structures produce concurrent abnormalities indeed. The present review gives a brief hint at the shared causative genes of both limb and orodental structures. The nosology either of skeletal and limb malformations or of orodental findings and the types of orodental anomalies were reported in these syndromes. Pathognomonic orodental features and Egyptian experiences are emphasized.

Quantification of hemoglobin peptides in Beta-thalassemia patients using tandem mass spectrometry for future national screening program Zeinab Y Abdallah, Soha S Nosier, Mona Ibrahim, Khalda Amr, Yasser Nassar, Ghada EL-Kamah Middle East Journal of Medical Genetics 2020 9(1):10-17 Background β-thalassemia is a hereditary blood disorder characterized by reduced or absent synthesis of the β chains of hemoglobin resulting in variable disease severity. The high carrier rate of thalassemia in Egypt makes it a priority genetic disease for prevention programs through detection of new cases and screening for carriers. Patients and methods In this study, for the first time in Egypt, tandem mass spectrometry (MS/MS) is used to distinguish patients with β-thalassemia from carriers and controls by calculation of α/β globin peptides ratio, as a contributory step in the management of this disease. The study included 40 patients with β-thalassemia referred from the Hereditary Blood Disorders Clinic, National Research Centre, 32 β-thalassemia carriers (parents of cases), and 34 healthy normal participants of matching age and sex. Dried blood spots from all participants were analyzed using MS/MS, followed by confirmatory molecular analysis. Results The results of MS revealed that α T1/β T1 globin peptides ratio is the most informative ratio that could be used to differentiate between β-thalassemia cases, carriers, and normal participants. The mean value of α T1/β T1 ratio for the studied cases was 4.24±0.97 (4.41±1.092 for thalassemia major and 3.83±0.88 for thalassemia intermedia), 1.93±0.30 for carriers, and 1.20±0.06 for controls, with statistical significant difference (P<0.001). Conclusion In conclusion, distinguishing patients from carriers and controls through tandem mass technology can serve as a cost-effective tool for national screening program for thalassemia in Egypt.

Effect of interleukin-10 polymorphism on susceptibility to type I diabetes in children with latent toxoplasmosis Raida S Yahya, Soha I Awad, Eman Hamed, Nanis S Elbeltagy, Rania A Abd Elazim Middle East Journal of Medical Genetics 2020 9(1):18-23 Objective The aim of this work was to investigate the effect of interleukin (IL)-10-1082 polymorphisms on susceptibility to type I diabetes in children with latent toxoplasmosis. Materials and methods IL-10 (−1082) polymorphisms were assessed by PCR in a small sample size of 75 patients with diabetes mellitus (DM) type I. Moreover, serum levels of C peptide and toxoplasma were determined by enzyme-linked immunosorbent assay. Glycosylated hemoglobin in blood was determined by colorimetry. Results Distribution of AA was higher in the case group (38.7%) compared with (18.7%) in the control group, whereas GG and AG were higher in the control group (45.3 and 36.0%, respectively) compared with (32.0 and 29.3%, respectively) in the case group. Regarding toxoplasma, it was more frequent in the case group (49.3%) compared with (30.7%) in the control group. The main risk factors of DM type I were high HbA1c [odds ratio (OR)= 10.7], positive toxoplasma finding (OR=4.7), high blood glucose (OR= 1.04), GG IL-10 polymorphism (OR=0.31), and low level of C peptide (OR=0.7). On the contrary, C peptide level and blood glucose were statistically significantly higher in positive toxoplasma cases (P<0.05). GG distribution was statistically significantly higher (P<0.001) in positive toxoplasma cases (48.6%) compared with (15.8%) in negative toxoplasma cases. The most significant predictors for G allele were positive toxoplasma result (OR=3.5) and high HbA1c level (OR=1.22). Conclusion GG genotype can no longer be viewed as a protective allele for DM type I, as higher IL-10 production with the ubiquitous nature of toxoplasma infection can lead to more pancreatic necrosis. The use of IL-10 as therapeutic cytokine for treatment of DM type I should be revised.

Genetic characterization of a patient with Cornelia de Lange syndrome with a novel NIPBL missense mutation Dalia F Hussen, Saida A Hammad, Ghada A Otaify, Alaaeldin G Fayez, Khaled M Refaat, Aya Elaidy, Mona S Aglan, Samia A Temtamy Middle East Journal of Medical Genetics 2020 9(1):24-29 Background Cornelia de Lange syndrome (CdLS) is a rare clinically and genetically heterogeneous disease. Cardinal phenotypic manifestations include specific dysmorphic facial features, growth retardation, intellectual disability, and upper limb anomalies. Mutations in five genes including NIPBL, SMC1A, SMC3, RAD21, and HDAC8 are known to be responsible for the syndrome, with the NIPBL gene mutation being the most prevalent (~80%). This study aimed to report the clinical, cytogenetic, and molecular characterization of a patient with CdLS with a heterozygous novel exonic missense mutation of the NIPBL gene. Patients and methods We have studied a male patient of 9 years and 4 months of age who presented with features suggestive of CdLS. Thorough clinical examination, conventional cytogenetic analysis, and molecular study using direct Sanger sequencing were performed. Results Clinical examination favored the diagnosis of CdLS. Conventional cytogenetic analysis revealed a normal 46, XY karyotype, with no evidence of premature sister chromatid separation. Molecular study showed a heterozygous novel exonic missense variant c. 2469G>T; p. (R657I) of the NIPBL gene. Conclusion A novel heterozygous exonic missense variant c. 2469G>T; p. (R657I) of the NIPBL gene was confirmed in our patient with CdLS. The phenotypic severity is probably correlated with the plausible effect of NIPBL gene mutation on the protein product rather than the variant type. The adverse effect of NIPBL gene mutation on the cohesion process mediated by cohesin complex is controversial.

One hundred years since Victor McKusick's birth: a tribute from Greece Christos S Bartsocas Middle East Journal of Medical Genetics 2020 9(1):30-34 Victor A. McKusick has been recognized as the world leading authority in medical genetics. Among his numerous achievements, we should point out his inspiration and the training of a large number of leading geneticists, OMIM, the 'Bar Harbor' courses, and his contribution to the Human Genome Project. Nonetheless, little is known of McKusick's active participation in genetic education of a large number of physicians worldwide. Greece is an example of his frequent presence there, always eager to friendly advice, assist, teach, and offer his vast knowledge and his unique and excellent personality and friendship to everyone around. Victor McKusick's relationship and experience with the Greek genetics community is briefly accounted.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Limb Lengthening & Reconstruction

Future Directions in Deformity Correction Peter H Thaller Journal of Limb Lengthening & Reconstruction 2020 6(2):93-95

Analysis of Different Osteotomies used in Hallux Valgus: A Systematic Review Sayed Mohamed Elgoyoushi, Mohamed A Omar, Sherif Dabash, Ahmed M Thabet, Yasser Elbatrawy Journal of Limb Lengthening & Reconstruction 2020 6(2):96-106

Curved "K" Wires: The Covert Villain in Circular External Fixators Charles Brian Howard, Eitay Farkash Journal of Limb Lengthening & Reconstruction 2020 6(2):107-115

Reference Values of the Femur and Tibia Mechanical Axes and Angles in the Sagittal Plane, Determined on the Basis of Three-Dimensional Modeling Leonid Nikolaevich Solomin, Alexander Igorevitch Utekhin, Victor A Vilenskiy Journal of Limb Lengthening & Reconstruction 2020 6(2):116-120

Defining the Anatomic Axis Joint Center Distance and Anatomic Axis Joint Center Ratio of the Distal Femur in the Coronal Plane Nando Ferreira, Andries Johannes Cornelissen, Marilize Burger, Aaron Kumar Saini Journal of Limb Lengthening & Reconstruction 2020 6(2):121-125

Acute Ulnar Osteotomy versus Gradual Distraction by External Fixator to Correct Missed Monteggia Type 1 Fracture-Dislocation; A Comparative Study Abdelhakim Ezzat Marei, Mahmoud A El.Rosasy Journal of Limb Lengthening & Reconstruction 2020 6(2):126-130

One-Week Accelerated PONSETI Method in the Management of Idiopathic Clubfeet Yasser Ali Elbatrawy Journal of Limb Lengthening & Reconstruction 2020 6(2):131-136

An External Fixator and Limited Release in the Treatment of Neglected, Recurrent, Relapsed and Resistant Talipes Equinovarus Deformity of the Feet Aditya K Agrawal, Manish R Shah, Malkesh D Shah, Neel H Patel, Takshay Gandhi, Sarvang M Desai, Jagdish J Patwa Journal of Limb Lengthening & Reconstruction 2020 6(2):137-141

Infected Regenerate in Ilizarov Surgery Barakat Sayed El-Alfy, Mohamed Fahmy Abdelaziz, Abdallah Ibrahim Elazanki Journal of Limb Lengthening & Reconstruction 2020 6(2):142-146

Evaluating the Accuracy of the Orthopedic Eye Gerhard Thiart, Marilize Burger, Nando Ferreira Journal of Limb Lengthening & Reconstruction 2020 6(2):147-152

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Orthopaedic Diseases and Traumatology

Editorial Ritesh Runu Journal of Orthopaedic Diseases and Traumatology 2020 3(3):103-103

Brodie's abscess: Brief review of key updates from the year 2010 Ganesh Singh Dharmshaktu Journal of Orthopaedic Diseases and Traumatology 2020 3(3):104-108 Brodie's abscess is an uncommon condition presenting as a subacute type of bone infection leading to localized pus collection. The common clinical presentation ranges from mild pain to serious functional impairment. The judicious radiological investigation helps in early diagnosis in suspected cases. The presence of a well-defined lytic lesion surrounded by sclerotic margins is a typical radiological feature that after exclusion may lead to a provisional diagnosis. The use of magnetic resonance imaging may prove supportive in further characterization of lesions and exclusion of related disorders. Final confirmation requires culture or histopathological evaluation following aspiration or biopsy following surgical drainage. The overall outcome has been good, following the appropriate diagnosis and management. This article attempts to give readers an overview of the reported cases or small series in the last decade (2010 onwards) in PubMed. This shall serve as a recollection of the spectrum of the clinical presentation and management of Brodie's abscess for educative purposes.

Arthroscopic correlation of ligamentous injury in adult knee with magnetic resonance imaging Rahul Kumar Gupta, Shubhda Sagar, Arunim Swarup, Abhay Shankar Dube, Avinash Kumar, Avinash Rastogi Journal of Orthopaedic Diseases and Traumatology 2020 3(3):109-111 Background: The purpose of this study was to compare the magnetic resonance imaging (MRI) and arthroscopic findings of internal derangement of adult knee joint. Aims and Objective: The objective was also to find out the value of MRI in the finding of ligamento-meniscal injury in adult knee joint during arthroscopy. Material and method: Ligamento-meniscal injury in 45 patients was subjected to MRI evaluation using hospital Sigma contour MRI with a field strength of 1.5 Tesla using 4-mm slice thickness, and those who had significant ligamento-meniscal findings underwent diagnostic and/or therapeutic arthroscopic procedure. Result: The sensitivity and specificity of MRI and arthroscopic findings of these injuries were found for medial meniscus to be 95.83% and 76.19%; for lateral meniscus 86.67% and 90%; for anterior cruciate ligament 97.37% and 85.71%; and posterior cruciate ligament 100% and 97.67%, respectively. Conclusion: The authors maintained that while arthroscopy, though invasive, is the gold standard to diagnose ligamento-meniscal injury, MRI is a noninvasive modality with high sensitivity and specificity for diagnosis and can be done to avoid arthroscopy, which should be best used for the therapy of significant ligamento-meniscal injuries.

The clinical characteristics and conservative management of isolated iliac wing fractures: A single-center experience from North India Ganesh Singh Dharmshaktu, Navneet Adhikari, Pankaj Mourya, Shailendra Singh Bhandari Journal of Orthopaedic Diseases and Traumatology 2020 3(3):112-115 Background: The fracture of iliac bone or blade is uncommon injury and usually a part of pelvic ring disruption with varied clinical presentation. Isolated iliac bone fractures are rare, with literature limited to few reports or small series. Materials and Methods: Retrospective data of consecutive cases of isolated iliac bone fractures were analyzed during the period of July 2014 to August 2019. Relevant patient demographics, mode of injury, pattern of fracture, associated adjacent regional or remote injuries were noted for each case. Details of previous treatment and that of treatment given by us were also noted for each case. Results: A total of 18 cases with isolated iliac bone fracture of the pelvic bone were noted. The mean age was 31.2 years (range: 22–54 years). All the cases were male, and fall from height was etiology in 12 cases, followed by road traffic accidents in the rest. Left- and right-side involvement was noted in 11 and 7 cases each. The fracture pattern was minimally displaced simple in 13 and comminuted in 5 cases. The conservative management was done in all cases. The radiological union and clinical stability of fractures were assessed as end points. The fracture united in all cases within 8–9 weeks and without any immediate or remote complication. Level of evidence - Level 5, Observational Study. Conclusion: The uncommon isolated iliac wing fractures require better recognition and documentation for its management. Further studies should provide a better understanding of these injuries and treatment guidelines.

Functional assessment of diaphyseal femoral fractures in pediatric age group managed by titanium elastic nail system: A prospective study Karan Siwach, Virender Kumar, Kunal Arora, Rajpal Beniwal, Ankit Mittal, Gaurav Nandal Journal of Orthopaedic Diseases and Traumatology 2020 3(3):116-120 Background: Femoral shaft fractures are common childhood injuries and are among common causes for hospitalization in children. Treatment varies with child's age. There is little room for question in treatment guidelines in children below the age of 3 years, but in the age group of 4–14 years, it is still a matter of debate. There is a trend toward surgical intervention with the advent of newer surgical techniques. This study aims to evaluate the functional outcome of titanium elastic nail system (TENS) for the treatment of femoral diaphyseal fractures in this age group. Materials and Methods: This study included 63 children between 4 and 14 years of age who sustained femoral diaphyseal fractures and were managed by TENS nailing during the period of the study between April 2017 and April 2020. Results: All patients showed union; there were no cases of nonunion or delayed union or implant failure. Three patients had exposed implant, and 15 developed superficial infections which subsided with antibiotic treatment. Forty-eight patients had excellent Flynn score, and 15 had a satisfactory score. Conclusion: In our series of patients, we concluded that TENS nailing in the study group was easy and reliable. As it is a load-sharing device and does not violate the physis, it allows early mobilization and maintenance of alignment. Other notable advantages include decreased risk of infection and undisturbed fracture hematoma. Superficial infection was one of the commonly observed complications which subsided with oral antibiotics.

Reduction and functional outcome of open reduction and internal fixation with plate versus minimally invasive screw fixation in displaced intra-articular calcaneum fractures Farhan Sozera, Sajid Younus, Naveed Memon, Nouman Memon, Kazim Raheem Najjad, Abdul Rafay Qazi Journal of Orthopaedic Diseases and Traumatology 2020 3(3):121-126 Introduction: Calcaneum fracture accounts for 2% of all fractures and 60% of all tarsal bone fractures. The most favored treatment for intra-articular fractures is open reduction and internal fixation using an extended lateral approach. The use of minimally invasive reduction and fixation of calcaneal fractures may have a role in this group of patients where there is a concern regarding wound healing and infection. Materials and Methods: This was a prospective study conducted from April 1, 2016, to April 30, 2018. Eighteen patients were included in the study. Preoperative and postoperative plain radiographs were compared for reduction parameters (improvement of Bohler's angle or Gissane's angle, the width of the calcaneus), Functional outcome was assessed using American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot score and visual analog scale. Results: The patients followed up for an average of 15.56 ± 4.85 months. No significant differences in reduction were observed between the open and closed groups (P > 0.05). The average AOFAS scores of the two groups were 76.45 ± 6.83 and 84.65 ± 7.65 (open versus closed) (P = 0.087). The mean visual analog scores of the open and closed groups were 1.38 ± 1.15 and 0.75 ± 0.45 (P = 0.034). The complication rates of the open and closed groups were 33% (3/9) and 10% (1/9) (P = 0.0053). Conclusion: Closed reduction and percutaneous screw fixation have shown better results in terms of outcome and complications. However, multicenter controlled randomized clinical trials are still required prior to widespread practical implementation.

A short-term comparative analysis of the efficacy of platelet-rich plasma therapy and corticosteroid injection in lateral epicondylitis Anant Akash, Sanjay Gupta, Apser Khan, Milan Jaiswal Journal of Orthopaedic Diseases and Traumatology 2020 3(3):127-132 Background: Tennis Elbow, a common overuse syndrome, is a tendonitis of the extensor muscles of the forearm mainly due to intratendinous degeneration associated with aging, repetitive movement, and vascular compromise. Autologous platelet-rich plasma (PRP) injections represent a new therapeutic option for chronic tendinopathies including tennis elbow. The purpose of the present study was to assess the therapeutic effect, efficacy, and safety of a single injection of PRP and corticosteroid in improving pain and function in patients suffering from lateral epicondylitis over a short term. Materials and Methods: Sixty patients with lateral epicondylitis were randomized into two groups to receive one injection of PRP or corticosteroid and were followed for 3 months. The two groups were compared as regards pain and functional improvement using the visual analogue scale (VAS) and the patient-rated tennis elbow evaluation (PRTEE) Score, by assessing the patients three times postintervention. Results: VAS scale showed that both modalities were effective in pain reduction. PRTEE score represented variably improved symptoms, i.e., decrease in pain and better function along with improvement in daily activity after 3 months in both groups. Conclusion: As the degree of pain relief achieved by the respective modalities was almost similar, the most important difference between the intervention groups was the duration of their effectiveness. PRP is suggested to be superior in the duration of pain relief when compared to corticosteroids. We can propose that PRP can be administered less often and more conveniently as compared to corticosteroid for lateral epicondylitis.

Segmental tibial fracture with physeal and diaphyseal fracture causing popliteal artery and common peroneal nerve injury in a 12-year-old child: A rare case with a unique injury mechanism Tungish Bansal, Sandeep Patel, Pebam Sudesh, Vishal Kumar Journal of Orthopaedic Diseases and Traumatology 2020 3(3):133-135 Proximal tibial physeal injuries with neurovascular injuries are rare. Here, we report the case of a 12-year-old boy with a rare fracture pattern that is segmental tibia fracture with physeal and diaphyseal fracture with popliteal artery and common peroneal nerve injury, which has never been reported earlier to the best of our knowledge. We also discuss the possible mechanism of injury and also describe the surgical decision-making and highlight the importance of prompt identification and early management of such patients for a good clinical outcome.

Dr. Bijay Narain Singh Rajeev Anand Journal of Orthopaedic Diseases and Traumatology 2020 3(3):136-136

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