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Abstract: Effective healthcare leadership is essential to ensure high-quality patient care and foster a supportive work environment for healthcare professionals. This review aims to consolidate existing healthcare leadership literature to provide evidence-based insights that can guide leadership development, improve team performance, and enhance patient care outcomes. A systematic search of academic databases such as PubMed, Scopus, Web of Science, CINAHL, Embase, and Google Scholar was performed using keywords related to healthcare leadership. Studies were selected based on their relevance, peer-reviewed status, and focus on healthcare settings. Thematic analysis was employed to synthesize findings from the selected studies. The review explores various leadership theories, including Great Man, trait, behavioral, transactional, transformational, and contingency theories, highlighting their relevance and application in healthcare. Effective healthcare leaders must possess traits such as vision, emotional intelligence, adaptability, and ethical integrity to navigate the complexities of modern healthcare. The review categorizes different leadership styles, including authoritarian, transformational, transactional, servant, and participative, and discusses their application in specific healthcare contexts. Leaders face challenges such as balancing personal and professional responsibilities, adapting to technological advancements, managing financial constraints, and ensuring regulatory compliance. Healthcare leadership requires a dynamic and adaptable approach that integrates various leadership theories and styles to address the unique challenges of the healthcare environment. This review underscores the importance of leadership development programs and calls for further research to explore the practical implementation of leadership strategies in diverse healthcare settings. The findings provide actionable insights for healthcare leaders to tailor their leadership styles to the specific needs of their teams and organizational contexts, ultimately enhancing patient care and operational efficiency., (Copyright © 2024 Journal of Postgraduate Medicine.)

Objective: The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates., Methods: Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees., Results: Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation., Conclusion: Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country., Competing Interests: None

Drug rash with eosinophilia and systemic symptoms (DRESS syndrome) is a severe, potentially life-threatening drug-induced hypersensitivity reaction characterized by cutaneous eruptions, fever, diffuse lymphadenopathy, along with eosinophilia and elevated liver enzymes. The severity and potential organ damage associated with DRESS mandates withdrawing the offending drug and provide a suitable replacement. We report a 55-year-old man who developed prolonged fever, generalized maculopapular rash and facial edema after 3 weeks of starting imatinib for chronic myeloid leukemia (CML). A diagnosis of DRESS was confirmed by eosinophilia and skin biopsy findings, along with a consistent RegiSCAR score. Imatinib was stopped and he was initiated on low-dose steroids, which led to complete resolution of rash and eosinophilia. A rechallenge with imatinib was positive, and he was switched to dasatinib for further therapy, following which he attained an optimal molecular response. DRESS following imatinib has only been reported in eight patients so far. In this report we summarize the current evidence for managing DRESS and its impact on the treatment of CML., Competing Interests: None

Context: Various radiographic features have been associated with temporomandibular joint disorders (TMDs); however, these characteristics have not been compared among different racial groups., Aims: To radiographically evaluate and compare craniofacial patterns and condylar findings suggestive of TMD among African, White, Chinese, Hispanic, and Indian racial groups., Settings and Design: This multicenter retrospective study used data from three private orthodontic practices and a University Orthodontic Clinic., Subjects and Methods: Panoramic and lateral cephalometric radiographs were collected from 250 subjects who were equally divided into five racial groups: Africans, Whites, Chinese, Hispanics, and Indians. All radiographs were initial records from patients seeking orthodontic treatment. Linear and angular cephalometric measurements were used to evaluate and compare cephalometric characteristics associated with TMD among groups. Panoramic radiographs were analyzed to compare the presence of condylar abnormalities and antegonial notching among groups., Statistical Analysis Used: One-way analysis of variance, followed by Tukey's test., Results: African and Chinese groups had the smallest mean cranial base measurements, while the Indians had the largest. The mean Y-axis value was significantly larger in the Chinese group compared with the other groups. Increased mandibular plane angles were seen in the Chinese and African patients, compared with subjects from other groups. The mean percentage of condylar anomalies was higher in the Chinese subjects compared with all other groups., Conclusions: Chinese patients presented with more radiographic features suggestive of TMD, whereas the Indians showed the least, compared with subjects from the White, Black, and Hispanic racial groups., Competing Interests: There are no conflicts of interest.

Objective: To assess the overall caesarean section (CS) rate, indications and outcomes in a tertiary hospital in North-western Nigeria., Materials and Methods: A cross-sectional study carried out over a period of two years. All patients who had caesarean section at any time within the day were noted and followed up till discharge. The socio-demographic data, types of CS, anaesthesia, indications, abdominal wall and uterine incisions, cadre of surgeon and feto-maternal outcomes were documented in a proforma. Statistical analysis was carried out using the EPI INFO 3.5.1 (CDC Atlanta Georgia, USA)., Result: The caesarean section rate was 11.3% (504/4462) of total deliveries. The highest rate of 44.6% (225/504) was among the primipara. The most common age group involved was 25 to 29 years. The emergency rate was 57.1% (288/504), while elective CS constituted 42.9% (216/504) of cases. The most common indication for emergency CS was obstructed labour 25.7% (30/288) and previous CS 39.8% (86/216) for elective CS. The complication rate was 13.3% (67/504) and the main complication was haemorrhage 59.7% (40/67). Complications were more with emergency CS compared to elective surgery (χ2 = 6.633, df = 1, P < 0.01) and with junior residents (χ2 = 15.9, df = 1, P < 0.001). There were 10 maternal and 60 perinatal deaths., Conclusions: The rate of caesarean section has been increasing gradually. There is need to improve on facilities and manpower in order to reduce morbidity and mortality.

Primitive Neuroectodermal Tumor of the kidney is a rare entity. Very few cases of primary renal PNET have been reported to date. Most literature about rPNET is isolated case reports. We report a case of rPNET in a 39-year-old male with a pre-operative diagnosis of renal cell carcinoma with renal vein thrombosis. The patient underwent radical nephrectomy with thrombolectomy, and histopathological examination revealed a highly aggressive tumor composed of monotonous sheets of round cells. Tumor cells were positive for CD 99 and FLI-1, hence confirming the diagnosis of Primitive Neuroectodermal Tumor. Post-surgery, patient was given VAC/IE-based adjuvant chemotherapy. In view of highly aggressive nature of this tumor, prompt diagnosis and imparting effective chemotherapy regimen to the patient is required, and it is important to differentiate PNET from other small round-cell tumors because of different therapeutic approach.

Background: Nottingham prognostic index (NPI) is a widely used integrated prognostic variable in patients with breast cancer. NPI has been correlated with tumor size, grade, lymph node stage and patient survival. The present study aimed at evaluating and correlating the various clinical and pathologic features of breast carcinoma with NPI., Methods: This study included 100 consecutive cases of primary breast carcinoma over a period of 2 years. Demographic data was noted and histomorphological features like tumor size, grade, lymph node involvement, necrosis, vascular invasion etc., were assessed. NPI was calculated as reported in the literature. Immunohistochemical staining for hormone receptors and CD34 (to calculate microvessel density [MVD]) was performed. Statistical analysis was used for correlation., Results: Of the 100 cases, 54% of the tumors were in T2 tumor size category (2-5 cm) and lymph node metastasis in 48% of the cases. NPI ranged from 2.3 to 7.3 with 54% of the cases in the intermediate NPI group (3.41-5.4). The mean MVD was 160.93 (±69.4/mm2). On statistical analysis, tumor size and grade, lymph node stage, mitotic rate, nuclear pleomorphism, necrosis and MVD showed a correlation with NPI (P < 0.05)., Conclusion: NPI is an important and useful prognostic indicator for breast cancer patients, which shows the correlation with other histomorphological prognostic features as well.

Background: The histological detection of axillary lymph node tumor metastases in cases of breast carcinoma is of major prognostic significance, but may be difficult when metastases are of microscopic size. The micrometastases can be detected either by immunohistochemistry (IHC) or serial sectioning. Aims: We investigated whether immunohistochemical techniques and serial sectioning can increase the accuracy of metastatic detection and compared the efficacy of both. Materials and Methods: Thirty cases of breast carcinoma were studied in all of whom the axillary lymph nodes had been reported as free of metastases. Blocks from these cases were serially sectioned and stained with hematoxylin and eosin and a single section was stained with monoclonal antibody to cytokeratin AE1/AE3 and epithelial membrane antigen. The positivity for micrometastases was correlated with size, number, grade and histological type of primary tumor, lymph node size and number. Results and Conclusion: In 5/30 previously unsuspected cases, micrometastases were revealed by IHC and in 1/30 by serial sectioning. These findings suggested that serial sectioning is a labor intensive, time consuming and impractical procedure. Micrometastases were more frequently detected with age of patient >50 years, Grade 2/3 tumor, tumor size >5 cm and more than one primary tumor. Immunohistochemical analysis can be recommended as a routine procedure or an adjunct to routine histological procedures for the correct staging of breast carcinoma and use of adjuvant chemotherapy, especially in the high risk group.

Endemic in major parts of Africa and Middle East, Schistosoma haematobium is a common cause of recurrent urogenital infections and obstetric complications such as spontaneous abortions, ectopic pregnancies, and low birth weight babies. The involvement of fallopian tubes is not rare in endemic areas and may predispose to ectopic pregnancy and infertility. Indian subcontinent is a very lowrisk region for schistosoma infection. Tubal schistosomiasis is not exceptional in endemic zones, but is rarely found in India. The species most often isolated is S. haematobium. Contamination occurs via vascular anastomoses between the bladder and the genital organs. We report a case of tubal schistosomiasis presenting as ruptured ectopic pregnancy discovered on a surgical specimen after salpingectomy.

Scrub typhus is a mite borne infectious disease caused by Orientia tsutsugamushi. It is a common cause of undifferentiated febrile illness in the Indian subcontinent. We present a case of scrub typhus with a rare ophthalmic manifestation.Our patient presented with fever and opsoclonus, was diagnosed to have scrub typhus and completely improved upon treatment. Opsoclonus complicates various medical diseases, including viral infections, toxin, encephalitis, brain tumors, and paraneoplastic syndromes. There has been only one previously reported case of opsoclonus in scrub typhus. This phenomenon highlights the increasingly complex presentation of common diseases. It also indicates there is much to be discovered about the immunopathogenesis of this infectious disease.

Background: Clinico-epidemiological profile of the Human immunodeficiency virus (HIV) epidemic in India is varied and depends on multitude of factors including geographic location. We analyzed the characteristics of HIV-infected patients attending our Immunodeficiency Clinic to determine any changes in their profile over five years., Settings and Design: A retrospective observational study., Materials and Methods: The study sample included all patients with HIV infection from January 1, 2003 to December 31, 2007. Diagnosis of HIV was made according to National AIDS Control Organization guidelines., Results: Of 3 067 HIV-infected patients, 1 887 (61.5%) were male and 1 180 (38.5%) were female patients. Mean age of patients was 35.1 ± 9.0 years. Majority (91.8%) of patients were in the age group of 15 to 49 years. Progressively increasing proportion of female patients was noted from year 2004 onward. Median CD4 count at presentation in year 2003 was 197/μl (Interquartile range [IQR] = 82.5-373) while in year 2007 it was 186.5/μl (IQR = 86.3-336.8). Mean CD4 count of male patients was 203.7 ± 169.4/μl, significantly lower as compared with female patients, which was 284.8 ± 223.3/μl (P value ≤0.05). Every year, substantial proportions of patients presenting to clinic had CD4 count<200/μl indicating advanced disease. Predominant route of transmission was heterosexual in 2 507 (81.7%) patients. Tuberculosis and oropharyngeal candidiasis were the most common opportunistic infections (OIs). Cryptococcal meningitis was the most common central nervous infection. Our patients had comparatively lower median CD4 counts at the time of presentation with various OIs., Conclusions: Patients had advanced stage of HIV infection at the time of presentation throughout five years. Females presented earlier during the course of HIV infection. There is need for early screening and increasing awareness in healthcare providers to make a diagnosis of HIV much sooner.

We report a case of 15-year-old girl who was diagnosed as a case of pituitary macroadenoma on computed tomography and magnetic resonance imaging (MRI) scans for her complains of diminished vision in the left eye and headache. On investigation she was found to have optic atrophy of left eye and primary hypothyroidism. She was started on thyroxin therapy in October 2008 and planned for transcranial excision of the tumor. Just before the date for planned surgery she developed mildly itchy vesico-bullous rash and the surgery was postponed. On histopathology and immunoflourescence studies it was confirmed to be the rash of dermatitis herpetiformis (DH) and treatment was started with corticosteroids in the last week of December 2008 and dapsone was added from mid January 2009. The lesions responded dramatically and within 6 weeks of starting treatment, she had become asymptomatic except for persisting diminution of vision. Repeat MRI scans in mid-February 2009 revealed total regression of pituitary mass. The case is being reported for interesting association of primary hypothyroidism, pituitary mass mimicking macroadenoma and DH; its successful outcome with medical management in the form of total regression of pituitary mass, thereby avoiding an unnecessary surgery.

Background: Dental caries affects populations of all ages in all the regions of the world, with the child patient being at the highest risk. Fifty percent of the permanent molars are decayed by the age of 12, due to lack of information about protection and occlusal morphology. Pit and fissure sealing undoubtedly plays a fundamental role in preventing occlusal caries. The most common approach to assess the sealing ability of pit and fissure sealants of tooth/restoration is the measurement of dye penetration along the interface., Aims and Objectives: The present study aims to evaluate the microleakage and penetration depth of three different types of dental materials, namely (A) Conventional pit and fissure sealant, (B) Flowable composite, (C) Flowable nanocomposite., Study Design: This in-vitro comparative study comprised of extracted human posterior teeth mounted as blocks., Materials and Methods: In the present study, microleakage and penetration depths of conventional sealants/flowable composite and nanocomposite were measured with the help of a dye under stereomicroscope., Statistical Analysis: A student't' test and Analysis of variance (ANOVA) tests were performed to compare the mean microleakage and penetration depth., Results: Microleakage was found to be highest for the flowable composites, and least for the conventional sealant. The nanocomposite values were intermediate. Penetration depth was highest for nanocomposite and least for flowable composite., Conclusions: According to the results, the nanocomposite was found to be an excellent dental material for penetration in deep pits and fissures, though it exhibits mild microleakage. Hence, it can be recommended for use in pediatric dental patients, as a pit and fissure sealing agent.

Aims: Various features have been described in the literature to differentiate benign from malignant lesions. The aim of the present study was to study the accuracy of each of these features and that of magnetic resonance imaging (MRI) in diagnosing malignant lesions., Materials and Methods: Fifty-five consecutive patients presenting with neoplastic (both benign and malignant) lesions diagnosed clinically and on ultrasound were studied and their MRI features were compared with the findings on surgical exploration and histopathologic examination., Results: There were 32 (58%) benign and 23 (42%) malignant masses. Malignant masses were more common in patients older than 20 years (83%), and these had symptoms of less than 6 months duration (75%), as against benign lesions. The swelling was painful in 8 malignant masses and these were more common in the upper limbs (61%). Various features of malignant lesions were size more than 5 cm in 83%, change in signal intensity from homogenous on T1-weighted images to heterogenous on T2-weighted images in 74%, irregular margins in 74%, and heterogenous contrast enhancement in 91%. The accuracy of these features was 76%, 58%, 78%, and 60%, respectively. Most benign and malignant lesions were intramuscular in location. A significant number (38%) of benign lesions were located in the intermuscular facial plane. Definitive diagnosis was made in 42% of the lesions., Conclusions: MRI is an excellent modality for evaluating soft tissue neoplasms; however, prediction of a specific diagnosis and differentiation of malignant and benign lesions is not always possible.

Painless dentistry, minimal intervention and thus giving comfort, relief and solace and instill positive attitude toward dental treatments, are some of the factors justifying the specialty of pediatric dentistry. Thus, this in vitro study was undertaken to compare the efficacy of a new chemomechanical caries removal agent, Papacarie (Formula and Acao), with conventional slow-speed rotary instrument (bur). Papacarie is a new formulation and has the main active ingredient papain, an endoprotein with bactericidal, bacteriostatic and anti-inflammatory actions. Twenty extracted human molar teeth with deep dentine caries and no enamel coverage were selected for the study. After the preparation of the teeth and removal of the caries with the respective methods, they were decalcified, dehydrated and embedded in paraffin blocks for histologic studies. Serial sections of 5 mum thickness were examined for the presence of bacteria under light microscope. Though complete removal of caries was achieved significantly in both the methods, there was less marked destruction of dentinal tubules in chemomechanical caries removal method by Papacarie. Thus, Papacarie is recommended as an efficient, easy to perform, comfortable and less destructive solution for the patient seeking an alternative to the conventional method.

Context: Speech abnormalities are common to the three Parkinsonian syndromes, namely Parkinson's disease (PD), progressive supranuclear palsy (PSP) and multiple system atrophy (MSA), the nature and severity of which is of clinical interest and diagnostic value., Aim: To evaluate the clinical pattern of speech impairment in patients with PD, PSP and MSA and to identify significant differences on quantitative speech parameters when compared to controls., Design and Setting: Cross-sectional study conducted in a tertiary medical teaching institute., Materials and Methods: Twenty-two patients with PD, 18 patients with PSP and 20 patients with MSA and 10 age-matched healthy controls were recruited over a period of 1.5 years. The patients were clinically evaluated for the presence and characteristics of dysarthria. This was followed by quantitative assessment of three parameters: maximum phonation time (MPT), semantic fluency and reading speed. The outcome measures were compared between the patient groups and with controls., Results: Patients with PD had hypophonic monotonous speech with occasional rushes of speech while patients with MSA and PSP had mixed dysarthria with ataxic and spastic elements respectively. All quantitative parameters were affected when compared to controls (P values<0.001, 0.012 and 0.008 respectively). Maximum phonation time was significantly less in PSP when compared to MSA and PD (P=0.015). Reading speed also showed a similar trend which was not statistically significant. Semantic fluency was comparable in all three groups., Conclusion: Dysarthria in PD, PSP and MSA have many overlapping but certain distinctive features as well which could serve as a diagnostic clue. Patients with PSP had profound speech impairment probably indicative of the more severe frontostriatial pathology.

Background: Abnormalities in the p53 tumor suppressor gene and in the expression of its protein are commonly seen in several tumors. The prognostic implication of these p53 abnormalities was studied in 55 patients with advanced head and neck cancers., Purpose: To identify p53 as a prognostic factor in assessment of response and survival outcome to radiotherapy in head and neck malignancies., Materials and Methods: This prospective study was carried out from April 1998 to December 1999. Fifty five patients with proven squamous cell carcinoma of the head and neck region were treated by radiotherapy (RT) (n=34) with or without chemotherapy (CT) (n=21). A dose of 70 Gy/35#/7 weeks was given with or without concurrent administration of weekly cisplatin (35 mg/m2). Paraffin sections obtained at the time of diagnosis, were examined immunohistochemically for p53 overexpression with monoclonal antibody DO-7 (DAKO). The scoring of p53 positive cells was carried out by a trained pathologist. Selected areas of p53 positive cells were viewed under high power field for quantitative assessment of the p53 over expression. A minimum of 1000 cells were counted and the labeling index (LI) was calculated in terms of percentage of p53 positive cells over the total number of cells counted. A 10% nuclear reactivity exhibiting chromogen positivity cutoff point was established., Observations: The data was analyzed as of January 2006. Median follow-up of all the patients was eight months (1-95 months). The median age of this study group was 58 years and of the 55 patients, 48 were males. Positive expression of p53 gene protein was documented by immunohistochemistry in 24 (44%) patients. Over expression of p53 was not associated with T or N stage, site of disease, radiation response or survival outcomes (P=0.143). Stage was the only independent prognostic variable, both for the response to treatment (radiation) and survival (P=0.01)., Conclusions: Over expression of p53 protein, when detected immunohistochemically, does not predict for radiation response in these tumors.

Background: Given the constraints of resources, thrombolysis for acute ischemic stroke (AIS) is under evaluation in developing countries. Prothrombin time (PT), platelet count and activated partial thromboplastin time (aPTT) may not be feasible within the time window., Aim: To evaluate the safety and efficacy of thrombolysis in selected patients without the coagulation profile., Design: Open, nonrandomized, observational study., Materials and Methods: Fifty-four stroke patients were classified using TOAST criteria (large artery atherosclerotic = 13; cardioembolic = 12; small vessel occlusion = 22; other determined etiology =three; undetermined etiology = four). The mean time to reach emergency was 2.4h (1.15-3.4), the mean door to CT, 24 min (10-47) and the door to recombinant tissue plasminogen activator (r-tPA) injection, 26.8 min (25-67). The NIHSS scores ranged from 11 to 22 (mean = 15.5 +/- 2.7). Patients with history of liver or renal disease or those on anticoagulants were excluded. The PT, aPTT and platelet count were not done. Recombinant tissue plasminogen activator was administered at a dosage of 0.9 mg/Kg., Results: Thirty-five patients (65%) significantly improved on NIHSS at 48 h (> or =4 points) (mean change = 10; range= 4-17). At one month, 43 (79%) improved on Barthel Index (mean change = 45%). One each developed small frontal lobe hemorrhage and recurrent stroke; one died of aspiration; and eight showed no improvement., Conclusions: Hyperacute thrombolysis was found useful and safe in selected patients with AIS even without the coagulation studies.

Background: Gabapentin is an antiepileptic drug. Its antiemetic effect is demonstrated in chemotherapy-induced acute and delayed onset of nausea and vomiting in breast cancer patients., Aim: To evaluate the antiemetic effect of gabapentin on incidence and severity of postoperative nausea and vomiting in laparoscopic cholecystectomy., Settings and Design: Double-blind, randomized, placebo-controlled study., Materials and Methods: Two hundred and fifty patients of ASA physical status I and II, scheduled for laparoscopic cholecystectomy were randomly assigned into two equal groups to receive 600 mg gabapentin or matching placebo two hours before surgery. Standard anaesthesia technique was used. Fentanyl was used as rescue postoperative analgesic. Ondansetron 4 mg was used intravenously as rescue medication for emesis. The total number of patients who had nausea or vomiting, and its severity and total fentanyl consumption in the first 24 hours were recorded., Statistical Analysis: "Z test" was used to test the significance of severity of post-operative nausea and vomiting between groups. Fentanyl consumed in each group (Mean+/-SD) within 24 hrs was compared using student t test. P value < 0.05 was considered significant., Results: There were no demographic difference between the two groups. Incidence of post-operative nausea and vomiting within 24 hrs after laparoscopic cholecystectomy was significantly lower in gabapentin group (46/125) than in the placebo group (75/125) (37.8% vs 60%; P =0.04). There was a significantly decreased fentanyl consumption in gabapentin group (221.2+/-92.4 microg) as compared to placebo group (505.9+/-82.0 microg; P =0.01)., Conclusion: Gabapentin effectively suppresses nausea and vomiting in laparoscopic cholecystectomy and post-operative rescue analgesic requirement.

Background: Predictors of survival and response to treatment in patients with small cell lung cancer (SCLC) are ill-defined and unclear. In an attempt to assess the impact of common presenting symptoms and laboratory values on survival, we undertook this retrospective review of patients with SCLC. To our knowledge, there is no study on survival in SCLC patients from the Indian subcontinent., Design: Retrospective Cohort study., Materials and Methods: All newly diagnosed small cell lung cancer cases from December 2001 through December 2004, were identified and clinical data on presenting symptoms and laboratory findings from their hospital records, noted. The influence of various pretreatment factors on survival was investigated using Kaplan-Meier plots and Cox multivariate regression model., Results: 76 subjects were included (84% males, 91% smokers). 57% patients had five or more symptoms at presentation. Cumulative symptom burden was strongly associated with survival (P =0.02). Survival was also significantly related with Karnofsky performance status (KPS) (P =0.04), disease extent (P =0.03) and symptomatic response to treatment (P< 0.001). Patients with higher hemoglobin (P =0.02), serum sodium (P =0.04) and serum globulin (P =0.02), survived significantly longer. By multivariate regression analysis, hemoglobin, KPS and brain metastases, were significant predictors of survival (P =0.01, P =0.02, P< 0.01 respectively)., Conclusion: Cumulative symptom burden, KPS, disease extent and symptomatic assessment of improvement after treatment, are useful predictors of survival. This has important clinical implications, keeping in view, the infrastructure and cost involved in more objective tests like CT scan, for evaluation of disease extent and prognosis. These findings can provide a simple basis for predicting prognosis in small cell lung cancer, especially in developing countries like ours.

Primary malignant melanoma is a rare neoplasm involving the uterine cervix. It may be misdiagnosed especially when amelanotic, in which case immunohistochemistry is useful in reaching the diagnosis. Though its staging and treatment are not yet well codified, prognosis is generally poor and unpredictable and hence early diagnosis is needed. We present the case of a 39-year-old female patient presenting with bleeding per vaginum. Speculum examination revealed an ulcero-proliferative growth involving the cervix. Microscopic examination of the tumor showed sheets of predominantly monomorphic cells, with few cells showing dark-brown pigment. The cells were positive for S-100 and HMB-45. In view of presence of subtle epitheliotropism, diagnosis of primary melanoma was entertained. Primary cervical melanoma should be considered while diagnosing cervical neoplasms, especially those displaying prominent eosinophilic nucleoli, even though this feature may be present only focally. Special staining and immunohistochemistry should be resorted to, whenever needed, to reach the diagnosis as early as possible. This is essential since cervical melanoma is incurable with the currently available therapies.

Odontomes are considered to be hamartomatous malformation rather than true neoplasm and are generally asymptomatic. Here is a case presentation of compound composite odontome with impacted deciduous teeth in an 11-year-old girl. A calcified mass was revealed in the radiograph and the case was finally diagnosed to be compound composite odontome. The mass was surgically excised.

The Protein Surplus Myopathies (PSM) are characterized by accumulation of protein aggregates, identifiable ultrastructurally, resulting due to mutations of the encoding genes. Desmin-related myopathies (DRM) are a form of PSM characterized by mutations of the desmin gene resulting in the formation of protein aggregates comprising mutant protein desmin and disturbance of the regular desmin intermediate network in the muscle fibers. We describe a rare case of DRM in a 23-year-old man who presented with complaints of difficulty in climbing stairs and running since the age of 5 years. EMG studies revealed a myopathic pattern. Muscle biopsy showed the features of muscular dystrophy with bluish rimmed vacuoles and sarcoplasmic inclusions, which were immunoreactive to desmin. Ultrastructural examination showed sarcoplasmic bodies and granulofilamentous inclusions. Although rare, the possibility of DRM/desminopathy should be considered in the presence of bluish rimmed vacuoles on light microscopy and characteristic ultrastructural inclusions. To the best of our knowledge this is the first case of DRM/desminopathy reported from India.

Background and Objective: Myasthenic crisis (MC) is one of the important and common complications in the natural history of myasthenia gravis (MG). MC can be precipitated by multiple factors including deficiency or excess of the acetylcholinesterase inhibitors (AChEI). Any episode of MC is an emergency requiring aggressive therapy. We studied the demographic, clinical and treatment-related characteristics of patients who developed MC., Materials and Methods: A retrospective study was conducted in patients with MC admitted during a 31-month period from February 1999 to August 2001, at a tertiary care center in India., Results: Eleven patients (9.69% of the total 114 patients with MG) were admitted with 12 episodes of MC. Mean age at presentation was 39.83 + 13.18 years with male predominance. Seven patients had undergone thymectomy previously; of which 2 had postoperative MC. Six patients had thymoma. Steroid or cholinesterase inhibitor withdrawal and infections were the commonest precipitating factors for MC. Patients required ventilatory support for median 14 days. They responded to low volume of plasma exchange (PE) (mean 854 ml / day with mean 6.5 cycles per patient)., Conclusions: This report highlights that the subset of Indian patients with MG who are at risk to develop MC belong to the 3rd and 4th decade, have bulbar symptoms at presentation and are associated with thymoma. Patients with MC should have judicious drug adjustments under supervision and should be treated aggressively during impending MC.

A natal tooth is that which is present in the oral cavity at the time of birth. Fibrous hyperplasia is a non-specific reactive lesion of soft tissues of unknown etiology usually associated with trauma or local irritation. Natal teeth can occur as an isolated dental finding, but many times they are associated wilh syndromes and developmental disturbances. This is a rare case, where in a natal tooth has led to the formation of a reactive fibrous hyperplasia in a four and half month old infant, a relationship not reported previously.

A female patient aged 6 years reported with brown coloured small sized teeth that were continuously wearing out. The teeth were badly attrited upto the gingival margins. The occlusal surfaces were flattened. The clinical and radiographical examination confirmed the case as Hereditary opalescent Dentin. The rationale for early diagnosis and treatment has been discussed.

Background: Caspase 8 is involved in apoptosis mediated by Fas and p55 tumor necrosis factor receptor ligation in HIV infection. Apoptosis is partially mediated by interleukin-1beta-converting enzyme (caspase-1)., Aims: We determined apoptosis, using caspase-1 and caspase-8, among patients with HIV infection, with and without tuberculosis (TB), those with TB alone and healthy individuals., Setting and Design: Cross-sectional analysis of caspase-1 and caspase-8 among patients with HIV infection, with and without TB, those with TB alone and healthy individuals., Materials and Methods: Nineteen HIV infected patients with TB (HIV+/TB+) and 20 with HIV infection without TB (HIV+/TB-) were studied. Fifteen individuals with TB alone were disease controls (HIV-/TB+) and 20 were healthy controls (HIV-/TB-). Caspases were measured by single-step ELISA using commercially available monoclonal antibodies., Statistical Analysis: Two-way ANOVA and Pearson's correlation coefficient., Results: Mean CD4 counts of HIV+/TB+ were lower than HIV+/TB- (p<0.05). OD value of caspase 1 in HIV+/TB+ was 0.295+0.05, while that in HIV+/TB- it was 0.302+0.18. It was 0.293+0.07 in HIV-/TB+ and in HIV-/TB- the values were 0.287+0.06. OD value of caspase 8 in HIV+/TB+ was 0.307+ 0.07, lower than HIV+/TB- (0.927+0.25). It was 0.008+0.03 in HIV-/TB+ and in HIV-/TB-, 0.074+0.004. Values of caspase 8 in patients with HIV infection (with/without TB) were higher than those with TB alone or healthy individuals (p<0.01). Levels of caspase 8 in HIV+/TB- were higher than patients with HIV+/TB+ (p<0.01)., Conclusion: Levels of caspase-1 are not different irrespective of presence or otherwise of TB and HIV infection. Fas-related apoptosis is higher in HIV infection. With concomitant TB, levels of caspase 8 were lower as compared with those without TB.

Talon cusp is a supernumerary crown structure, a developmental disturbance in the shape of teeth that causes various diagnostic, functional and esthetic problems. Some synonyms for talon cusp are dens evaginatus of anterior teeth, interstitial cusp, tuberculated tooth, odontoma of the axial core type, evaginated odontoma, enamel pearl, supernumerary cusp etc. The lingual location on incisors, which frequently affects occlusion, is pathognomonic of the talon cusp. This report describes a rare odontogenic, isolated anomaly rather than an integral part of any disorder, a case of talon shaped cusp projecting from the labial surface of a maxillary permanent central incisor.

An interesting lesion is presented, wherein a tiny traumatic perforation of the buccal mucosa and buccinator muscle forced a large portion of the buccal fat pad to extrude into the oral cavity. Such a situation can alarm any clinician & reinforces the importance of careful history taking and thorough examination, before treating patients.

A case report of a pituitary tuberculoma, with magnetic resonance imaging (MRI) features is described. The patient was treated with anti-tuberculous chemotherapy, and a follow-up MRI after 6 months showed good response. The relevant literature is briefly reviewed.

A 61-year old woman presented to us with fever, weakness and ecchymotic patches for one year. She had leucocytosis, anemia and thrombocytopenia. Peripheral blood smear showed 62% neutrophils, 32% myelocytes and metamyelocytes, 2% promyelocytes, 1% blasts, 2% monocytes, 1% lymphocytes but no basophils and marked dyspoiesis. Bone marrow picture was essentially the same. A diagnosis of atypical chronic myeloid leukemia was suggested. The correct diagnosis of chronic myeloid leukemia-accelerated phase was, however, made on cytogenetic analysis which showed Philadelphia chromosome (Ph) and isochromosome 17q [i(17q)]. This case describes a rare and diagnostically difficult presentation of CML arising out of a combination of prominent dyspoiesis and near absence of peripheral blood basophils.

We describe the magnetic resonance imaging (MRI) signal characteristics of isolated (solitary lesion) intra fourth ventricular cysticercus cyst in 4 patients who clinically presented with obstructive hydrocephalus. All patients had routine MRI sequences (T1, T2, & proton density-weighted imaging), Fluid Attenuation Inversion Recovery (FLAIR), and post-gadolinium imaging followed by cerebrospinal fluid (CSF) flow study. It revealed a CSF signal intensity (on all pulse sequences), intra fourth ventricular cyst with a nidus (scolex), and wall enhancement. On T1-weighted and FLAIR images, the cyst wall and nidus (scolex) were seen in 3 cases, which were not seen in other routine sequences. The CSF flow study showed the intraluminal nature of the cyst. The MRI features suspected a cysticercus cyst, and per-operative findings and histopathological examination confirmed the diagnosis. The review of literature of the intra fourth ventricular cyst is briefly discussed.