Background/Aims: Sigmoid esophagus and/or megaesophagus are considered as an advanced stage in the natural history of achalasia cardia. The role of peroral endoscopic myotomy (POEM) in these subset of patients is emerging. We performed a systematic review and metanalysis to study the efficacy of POEM in advanced achalasia cardia with sigmoid and megaesophagus. Methods: A literature search in PubMed and Embase was done from inception till August 3, 2021 to look for studies reporting exclusively on the role of POEM in advanced achalasia cardia with sigmoid and/or megaesophagus. The random effect method with inverse variance approach was used for the computation of pooled prevalence. For 2 groups’ analysis of continuous outcome standardized mean difference was used as the summary measure. Results: Eleven studies with 428 patients were included for analysis. The pooled technical and clinical success was 98.27% (95% CI, 96.19-99.22; I 2 = 0%) and 89.38% (95% CI, 84.49-92.86; I 2 = 26%) and on subgroup analysis into sigmoid and megaesophagus it was (98.06% [95% CI, 95.41-99.19; I 2 = 0%], 98.47% [95% CI, 92.72-99.69; I 2 = 0%] and 87.92% [95% CI, 80.68-92.70; I 2 = 37%], 88.36% [95% CI, 62.62-97.17; I 2 = 77%]) respectively. The clinical success at < 1 year and 1-3 year follow-up was 89.37% (95% CI, 82.82-93.61; I 2 = 0%) and 88.66% (95% CI, 81.65-91.22; I 2 = 46%) respectively. There was a significant reduction in the post-POEM scores with standardized mean difference for Eckardt score (4.81), for integrated relaxation pressure at 4 seconds (1.93), and for lower esophageal sphincter pressure (2.06). Conclusions POEM is an effective modality of treatment even in the subset of patients of advanced achalasia cardia with sigmoid and megae sophagus.

PURPOSE: The effective half-life of radioiodine is an important parameter for dosimetry in differentiated thyroid cancer patients, particularly in children. We determined the pre-therapy and post-therapy effective half-life in different types of lesions, i.e., remnant, node, or lung metastases.METHODS: Of 84 patients recruited, 27 were < 18 years (group 1) and the remaining 57 were between 18 and 21 years (group 2). A total of 114 studies were conducted and 253 lesions were analyzed. Serial whole-body scans were acquired at 24, 48, and ≥ 72 h after administration of iodine-131. Region of interests was drawn over lesions to determine counts in the lesion. Time versus counts graphs were plotted and mono-exponentially fitted to determine effective half-life.RESULTS: The post-therapy effective half-life was found to be lesser than pre-therapy effective half-life in all types of lesions and in all groups. Median effective half-life was found maximum in intact lobe, minimum in the lung, and intermediate in remnant and nodes. In the assessment of all lesions together, pre- and post-therapy median and interquartile range (IQR) effective half-life were 59.8 (37–112) h and 48.6 (35.2–70.8) h (p < 0.0001) in group 1, 73.9 (46.2–112.7) h and 60 (57.4–85.9) h (p < 0.0001) in group 2, and 68.6 (41.53–112.36) h and 54.7 (36–80.6) h (p < 0.0001) in combined group, respectively. Importantly, the pre- and post-therapy median effective half-life serially dropped after each successive cycles of iodine-131.CONCLUSIONS: There was a significant difference in pre-therapy and post-therapy effective half-life in all types of lesions. These results may have implications in calculating the correct therapeutic dose in children and in young adults.
Child ; Half-Life ; Humans ; Lung ; Neoplasm Metastasis ; Thyroid Gland ; Thyroid Neoplasms ; Young Adult

PURPOSE: The effective half-life of radioiodine is an important parameter for dosimetry in differentiated thyroid cancer patients, particularly in children. We determined the pre-therapy and post-therapy effective half-life in different types of lesions, i.e., remnant, node, or lung metastases. METHODS: Of 84 patients recruited, 27 were < 18 years (group 1) and the remaining 57 were between 18 and 21 years (group 2). A total of 114 studies were conducted and 253 lesions were analyzed. Serial whole-body scans were acquired at 24, 48, and ≥ 72 h after administration of iodine-131. Region of interests was drawn over lesions to determine counts in the lesion. Time versus counts graphs were plotted and mono-exponentially fitted to determine effective half-life. RESULTS: The post-therapy effective half-life was found to be lesser than pre-therapy effective half-life in all types of lesions and in all groups. Median effective half-life was found maximum in intact lobe, minimum in the lung, and intermediate in remnant and nodes. In the assessment of all lesions together, pre- and post-therapy median and interquartile range (IQR) effective half-life were 59.8 (37–112) h and 48.6 (35.2–70.8) h (p < 0.0001) in group 1, 73.9 (46.2–112.7) h and 60 (57.4–85.9) h (p < 0.0001) in group 2, and 68.6 (41.53–112.36) h and 54.7 (36–80.6) h (p < 0.0001) in combined group, respectively. Importantly, the pre- and post-therapy median effective half-life serially dropped after each successive cycles of iodine-131. CONCLUSIONS There was a significant difference in pre-therapy and post-therapy effective half-life in all types of lesions. These results may have implications in calculating the correct therapeutic dose in children and in young adults.

The Epidural blood patch is considered the gold standard for managing postdural puncture headache when supportive measures fail. However, it is a procedure which can lead to another inadvertent dural puncture. Other potential adverse events that could occur during a blood patch are meningitis, neurological deficits, and unconsciousness. The bilateral greater occipital nerve block has been used for treating chronic headaches in patients with PDPH with a single injection. This minimally invasive, simple procedure can be considered for patients early, along with other supportive treatment, and an epidural blood patch can be avoided.
Blood Patch, Epidural ; Headache Disorders ; Humans ; Meningitis ; Nerve Block ; Pain Management ; Post-Dural Puncture Headache ; Punctures ; Ultrasonography ; Unconsciousness

Basal cell carcinoma (BCC) of the scrotum is uncommon and its pathogenesis is not well understood. The clinical behaviour of scrotal BCC is thought to be more aggressive and has a higher metastatic potential than BCC of other regions. The mainstay of treatment for localized scrotal BCC is wide local excision, while metastatic disease may need systemic chemotherapy for palliative control. A rare clinical scenario of scrotal BCC presenting concurrently with another metastatic cancer has never been reported. The present case illustrates the diagnostic challenge and management dilemma due to simultaneous presentation of scrotal BCC and metastatic squamous cell carcinoma (SCC). A 70-year-old man complained of a non-healing scrotal ulcer while he was being investigated for metastatic squamous cell carcinoma (SCC) of the external auditory meatus. The scrotal lesion was initially thought to be metastatic SCC. It was later confirmed to be BCC with biopsy and histopathological examination. He underwent surgical resection of the scrotal BCC for local control followed by palliative chemotherapy with cisplatin and radiotherapy for lymph node metastases. He remained well and did not have any local recurrence following 6 months after palliative treatment. Surgery coupled with palliative chemoradiation can offer good quality of life for patients with scrotal BCC and concurrent metastatic SCC.
Carcinoma, Basal Cell ; Carcinoma, Squamous Cell

BACKGROUND:This cross-sectional study aimed to assess the knowledge, attitude and anxiety pertaining to basic life support (BLS) and medical emergencies among interns in dental colleges of Mangalore city, Karnataka, India. METHODS:The study subjects comprised of interns who volunteered from the four dental col eges. The knowledge and attitude of interns were assessed using a 30-item questionnaire prepared based on the Basic Life Support Manual from American Heart Association and the anxiety of interns pertaining to BLS and medical emergencies were assessed using a State-Trait Anxiety Inventory (STAI) Questionnaire. Chi-square test was performed on SPSS 21.0 (IBM Statistics, 2012) to determine statistical y significant differences (P<0.05) between assessed knowledge and anxiety. RESULTS:Out of 183 interns, 39.89％ had below average knowledge. A total of 123 (67.21％) reported unavailability of professional training. The majority (180, 98.36％) felt the urgent need of training in basic life support procedures. Assessment of stress showed a total of 27.1％ participants to be above high-stress level. Comparison of assessed knowledge and stress was found to be insignificant (P=0.983). CONCLUSION:There was an evident lack of knowledge pertaining to the management of medical emergencies among the interns. As oral health care providers moving out to the society, a focus should be placed on the training of dental interns with respect to Basic Life Support procedures.

PURPOSE: Ocular manifestations in snake-bite injuries are quite rare. However, the unusual presentations, diagnosis and their management can pose challenges when they present to the ophthalmologist. Early detection of these treatable conditions can prevent visual loss in these patients who are systemically unstable and are unaware of their ocular condition. To address this, a study was conducted with the aim of identifying the various ocular manifestations of snake bite in a tertiary care center. METHODS: This is a one-year institute-based prospective study report of 12 snake bite victims admitted to a tertiary hospital with ocular manifestations between June 2013 to June 2014, which provides data about the demographic characteristics, clinical profiles, ocular manifestations, and their outcomes. RESULTS: Twelve cases of snake bite with ocular manifestations were included of which six were viper bites, three were cobra bites and three were unknown bites. Six patients presented with bilateral acute angle closure glaucoma (50%), two patients had anterior uveitis (16.6%) of which one patient had concomitant optic neuritis. One patient had exudative retinal detachment (8.3%), one patient had thrombocytopenia with subconjunctival hemorrhage (8.3%) and two patients had external ophthalmoplegia (16.6%). CONCLUSIONS: Bilateral angle closure glaucoma was the most common ocular manifestation followed by anterior uveitis and external ophthalmoplegia. Snake bite can result in significant ocular morbidity in a majority of patients but spontaneous recovery with anti-snake venom, steroids and conservative management results in good visual prognosis.
Acute Disease ; Adolescent ; Adult ; Animals ; Antivenins/therapeutic use ; *Elapidae ; Female ; Follow-Up Studies ; Glaucoma, Angle-Closure/diagnosis/*etiology/therapy ; Humans ; Male ; Middle Aged ; Ophthalmoplegia/diagnosis/*etiology/therapy ; Prospective Studies ; Snake Bites/*complications/diagnosis/therapy ; Snake Venoms/*poisoning ; Tertiary Healthcare ; Time Factors ; Uveitis, Anterior/diagnosis/*etiology/therapy ; *Viperidae ; Young Adult

The authors wish to report a case of bilateral acute anterior uveitis and optic disc edema following a hemotoxic snake bite, in order to highlight the concomitant occurrence of these conditions and the potential adverse effects of anti-snake venom (ASV). A 35-year-old male was bitten by a viper at seventeen thirty hours, and was started on ASV. Two days following treatment he experienced sudden onset redness and painful diminution of vision in both eyes (OU). On examination, the patient's visual acuity (VA) in OU was 20/200. Examination revealed fresh keratic precipitates, cells, and flare in the anterior chamber (AC), posterior synechiae, sluggish and ill-sustained pupillary reaction, and hyperemic, edematous disc with blurred margins in OU. He was started on topical steroids, cycloplegics and intravenous methylprednisolone. Following treatment, the patient showed improvement and was continued on topical medications and oral prednisolone tapered over 3 weeks, after which VA OU improved, the AC showed no cells and flare and disc edema resolved. Uveitis and optic disc edema in snake bite can either be due to the direct toxic effects of the venom or the effect of ASV. Steroids have a beneficial role in the management of these symptoms.
Acute Disease ; Adult ; Antivenins/*adverse effects ; Glucocorticoids/administration & dosage ; Humans ; Hyperemia/drug therapy/etiology/pathology ; Male ; Methylprednisolone/administration & dosage ; Papilledema/drug therapy/*etiology/pathology ; Snake Bites/*complications/*therapy ; Uveitis, Anterior/drug therapy/*etiology/pathology

BACKGROUND: Subacute sclerosing panencephalitis (SSPE) is a delayed and fatal manifestation of measles infection. Fulminant SSPE is a rare presentation in which the disease progresses to death over a period of 6 months. The clinical features are atypical and can be misleading. CASE REPORT: We report herein a teenage boy who presented with acute-onset gait ataxia followed by right hemiparesis that evolved over 1 month, with left-hemispheric, delta-range slowing on the electroencephalogram (EEG). Magnetic resonance imaging disclosed multiple white-matter hyperintensities, suggesting a diagnosis of acute disseminated encephalomyelitis. He received intravenous steroids, and within 4 days of hospital admission he developed unilateral slow myoclonic jerks. Repeat EEG revealed Rademecker complexes, pathognomonic of SSPE, and an elevated titer of IgG antimeasles antibodies was detected in his cerebrospinal fluid. The disease progressed rapidly and the patient succumbed within 15 days of hospitalization. The diagnosis of SSPE was confirmed by autopsy. CONCLUSIONS: This case illustrates the difficulty of recognizing fulminant SSPE when it manifests with asymmetric clinical and EEG abnormalities.
Adolescent* ; Antibodies ; Ataxia* ; Autopsy ; Cerebrospinal Fluid ; Diagnosis ; Electroencephalography ; Encephalomyelitis, Acute Disseminated ; Gait Ataxia ; Hospitalization ; Humans ; Immunoglobulin G ; Magnetic Resonance Imaging ; Male ; Measles ; Myoclonus ; Paresis* ; Steroids ; Subacute Sclerosing Panencephalitis*

Inflammatory Pseudotumor (IP) of bladder is one of a variety of lesions which may arise from spindle cell lesions in the bladder. It is benign in nature compared to the other end of the spectrum of spindle cell lesions, such as sarcoma, sarcomatoid carcinoma and leiomyosarcoma. The diagnosis of IP and its differentiation from a malignant pathology is a diagnostic dilemma for Urologist and Pathologist as both entities share certain similar morphological and histo-pathological appearance as well as immuno-histo chemistry staining. It is however crucial to avoid misdiagnosis as the treatment option varies significantly between a radical or partial cystectomy with future surveillance cystoscopes. Hereby, we highlight a case of a benign variant of spindle cell tumour of bladder which needed second pathology review for confirmation and thus avoiding a radical cystectomy. We also review the literature on its presentation and emphasis characteristics differentiating a benign from a malignant pathology.