The climatological mean barotropic vorticity budget is analyzed to investigate the relative importance of surface wind stress, topography and nonlinear advection in dynamical balances in a global ocean simulation. In addition to a pronounced regional variability in vorticity balances, the relative magnitudes of vorticity budget terms strongly depend on the length-scale of interest. To carry out a length-scale dependent vorticity analysis in different ocean basins, vorticity budget terms are spatially filtered by employing the coarse-graining technique. At length-scales greater than 10o (or roughly 1000 km), the dynamics closely follow the Topographic-Sverdrup balance in which bottom pressure torque, surface wind stress curl and planetary vorticity advection terms are in balance. In contrast, when including all length-scales resolved by the model, bottom pressure torque and nonlinear advection terms dominate the vorticity budget (Topographic-Nonlinear balance), which suggests a prominent role of oceanic eddies, which are of Ο(10-100) km in size, and the associated bottom pressure anomalies in local vorticity balances at length-scales smaller than 1000 km. Overall, there is a transition from the Topographic-Nonlinear regime at scales smaller than 10o to the Topographic-Sverdrup regime at length-scales greater than 10o. These dynamical balances hold across all ocean basins; however, interpretations of the dominant vorticity balances depend on the level of spatial filtering or the effective model resolution. On the other hand, the contribution of bottom and lateral friction terms in the barotropic vorticity budget remains small and is significant only near sea-land boundaries, where bottom stress and horizontal friction generally peak.

Most of the ocean's kinetic energy is contained within the mesoscale eddy field. Models that do not resolve these eddies tend to parameterize their impacts such that the parameterized transport of buoyancy and tracers reduces the large-scale available potential energy and spreads tracers. However, the parameterizations used in the ocean components of current generation Earth System Models (ESMs) rely on an assumption of a flat ocean floor even though observations and high-resolution modelling show that eddy transport is sensitive to the potential vorticity gradients associated with a sloping seafloor. We show that buoyancy transport coefficient diagnosed from idealized eddy-resolving simulations is indeed reduced over both prograde and retrograde bottom slopes (topographic wave propagation along or against the mean flow, respectively) and that the reduction can be skilfully captured by a mixing length parameterization by introducing the topographic Rhines scale as a length scale. This modified 'GM' parameterization enhances the strength of thermal wind currents over the slopes in coarse-resolution, non-eddying, simulations. We find that in realistic global coarse-resolution simulations the impact of topography is most pronounced at high latitudes, enhancing the mean flow strength and reducing temperature and salinity biases. Reducing the buoyancy transport coefficient further with a mean-flow dependent eddy efficiency factor, has notable effects also at lower latitudes and leads to reduction of global mean biases.

Migao volatile oil (MVO), a traditional Chinese medicine extract, exerts a curative effect on coronary heart disease (CHD). In this study, gas chromatography-mass spectrometry (GC-MS) was used to determine the fingerprints of 10 MVO batches, and 27 common components were identified. The anti-CHD activities of the different MVOs were determined using ELISA kits, and haematoxylin and eosin staining was used to assess the histopathological injury in myocardial tissues. Three mathematical models were used to analyse multiple bioactive indices, and an anti-CHD-guided spectrum-effect relationship approach was developed to discover MVO quality control (QC) markers. α-phellandrene, p-cymene, 1,8-cineole, linalool, α-terpineol, α-cubebene, α-copaene, α-humulene, dihydroagarofuran, and δ-cadinene all showed good affinity for target proteins connected to CHD, showing their potential as QC markers. Based on the anti-CHD-guided spectrum-effect relationship approach, a bioactive constituent-based holistic QC method was successfully developed for MVO, which could provide a valuable reference for related QC research.

Due to human activities, the overabundance of regional nitrogen/ phosphorus (N/P) has a huge impact on ecological environment worldwide. It’s quite necessary to comprehensively understand the human-induced N/P inputs and spatiotemporal variations of nutrients in the river. As the adjustment to the spatial structure of Beijing, the Beijing’s sub-center is an important strategic position in promoting the coordinated development of Beijing-Tianjin-Hebei. In this study, the dynamic changes of NH 3N and TP from 2012 to 2022 were analyzed, then the net anthropogenic N input (NANI), net anthropogenic P input (NAPI) was estimated in the Beijing’s sub-center. The results showed that both NH 3N and TP had an overall downward trend with a three-stage pattern. The NANI and NAPI declined from 5.68 x 10 4 kg∙km −2∙a −1 and 0.95 x 10 4 kg∙km −2∙a −1 to 0.78 x 10 4 kg∙km −2∙a −1 and 0.15 x 10 4 kg∙km −2∙a −1, respectively. The chemical fertilizers input accounted for the largest part at 53%~81% of NANI and 49%~80% of NAPI. There were high values of N and P input in the southeast of Tongzhou, and the fluxes of N and P were positively correlated with the inputs of anthropogenic N and P in the Chaobai River Basin and the Beiyun River Basin. This study would provide the foundation for setting priorities and enacting more targeted N/P management strategies in the Beijing’s sub-center.

Eosinophils are known to play a crucial role in equine insect bite hypersensitivity (IBH), an allergic and pruritic dermatitis. Given the relevant role of eosinophils in disease pathology, a virus-like particle (VLP)-based vaccination targeting equine Interleukin (eIL)-5 has been shown to significantly reduce eosinophil levels in the blood and hence reduced IBH symptoms in horses. The aim of the present study was to assess the presence of different eosinophil subtypes in horses, describe characteristics of these subtypes and evaluate the effect of eIL-5-CuMVTT vaccination on these subtypes. The study involved healthy horses, untreated IBH horses, eIL-5-CuMVTT vaccinated and placebo-treated IBH horses, assessed in parallel during the same IBH season. For the first time, this study showed presence of two distinct eosinophil subtypes in horses. An inflammatory subtype was associated with allergy, which had a significantly larger cell size, increased intracellular granula and higher surface expression of the integrin CD49f hi. Regulatory steady-state eosinophils were identified in healthy blood sample and with smaller relative cell size, had less intracellular granula and significantly lower levels of surface integrin CD49f dim. The eIL-5-CuMVTT vaccination significantly reduced eosinophil levels in the blood throughout the whole IBH season, indicating IL-5-dependence of inflammatory eosinophils. However, it did not alter the phenotype of the remaining cells. The mechanism of action of vaccination likely acts by limiting availability of eosinophils in the blood for extravasation into the skin.

Background Respiratory syncytial virus (RSV) infection in infants is a major cause of viral bronchiolitis and hospitalisation. We have previously shown in a murine model that ongoing infection with the gut helminth Heligmosomoides polygyrus ( H. polygyrus) protects against RSV infection through type I interferon (IFN-I) dependent reduction of viral load. Yet, the cellular basis for this protection has remained elusive. Given that recruitment of mononuclear phagocytes to the lung is critical for early RSV infection control, we assessed their role in this coinfection model. Methods Mice were infected by oral gavage with H. polygyrus. Myeloid immune cell populations were assessed by flow cytometry in lung, blood and bone marrow throughout infection and after secondary infection with RSV. Monocyte numbers were depleted by anti-CCR2 antibody or increased by intravenous transfer of enriched monocytes. Results H. polygyrus infection induces bone marrow monopoiesis, increasing circulatory monocytes and lung mononuclear phagocytes in a IFN-I signalling dependent manner. This expansion causes enhanced lung mononuclear phagocyte counts early in RSV infection that may contribute to the reduction of RSV load. Depletion or supplementation of circulatory monocytes prior to RSV infection confirms that these are both necessary and sufficient for helminth induced antiviral protection. Conclusions H. polygyrus infection induces systemic monocytosis contributing to elevated mononuclear phagocyte numbers in the lung. These cells are central to an anti-viral effect that reduces the peak viral load in RSV infection. Treatments to promote or modulate these cells may provide novel paths to control RSV infection in high risk individuals.

Objectives: To investigate the association and the potential value of prelabour fetal heart rate short-term variability (STV) determined by computerised cardiotocography (cCTG) and maternal-foetal Dopplers in predicting labour outcomes. Design: Prospective cohort study. Setting: The Prince of Wales Hospital, a tertiary maternity unit, in Hong Kong SAR. Population: Women with a term singleton pregnancy in latent phase of labour or prior to labour induction were recruited during May 2019 – November 2021. Methods: Ultrasonographic assessment of foetal growth, Doppler velocimetry and the cCTG monitoring including Dawes-Redman CTG analysis. Main Outcome Measures: Umbilical Cord arterial pH, emergency delivery due to pathological CTG during labour and neonatal intensive care unit (NICU)/special care baby unit (SCBU) admission. Results: Of the 400 cases, 34 (8.5%) women underwent emergency delivery for pathological CTG during labour. A total of 6 (1.50%) and 148 (37.00%) newborns required NICU and SCBU admission, respectively. Middle cerebral artery pulsatility index (MCA-PI) and MCA-PI z-score were significant lower in pregnancies that required emergency delivery for pathological CTG during labour compared with those who did not [1.23 (1.07-1.40) vs 1.40 (1.22-1.64), p=0.002 and 0.55 (±1.07) vs 0.12 (±1.06), p=0.049,]. Umbilical cord arterial pH was associated with STV (r = 0.107, p = 0.035) and the independent predictors for umbilical cord arterial pH were smoking (p = 0.006) and STV (p = 0.025). Conclusions: In pregnant women admitted in latent phase of labour or for induction of labour at term, cCTG STV is associated with umbilical cord arterial pH but not predictive of emergency delivery due to pathological CTG during labour.

A document by Sophie Strong. Click on the document to view its contents.

Aim The prevalence of undocumented medical treatments among children is a significant issue, as well as many EU countries lack access to newly developed children friendly medicines. Consequently, there is a pressing need for supplementary resources that can facilitate informed decision-making regarding children’s medication. We therefore aim to describe the process of establishing a children’s Drug and Therapeutics Committee (cDTC), as well as the preparing and implementation of recommendations for children in the Capital region of Denmark Method Following the guidelines outlined by the World Health Organization a cDTC was established. Recommendations for pediatric medication practice were constructed from assessments of medication use patterns among children in the Capital Region between 2019 and 2021. The recommendations were meticulously crafted based on evaluation of the current marketing authorization landscape and existing best available evidence. Results In 2019, the Capital Region established the first cDTC supported by expert councils and an editorial board. A total of 2.429 purchase item numbers covering 1.222.846 defined daily doses and 592.088 purchased packages covering 10.200.000 defined daily doses were identified in the secondary and primary sectors, respectively. Three comprehensive lists covering recommendations for newborns and children were published between 2021 and 2020 totaling 331 recommended pharmaceutical products. The recommendations primarily intended for use in the secondary healthcare sector were implemented through the revision of 38 pediatric- and 6 neonatal product ranges throughout Capital region. Conclusion Recommendation lists for children governed by a cDTC provide a rational auxiliary tool that can be immediately implemented in the clinic.

A case of phantom pain and stump pain that was effectively controlled by ultrasound-guided ulnar and median peripheral nerve blocksShunya Sekiguchi, Yusuke Ishida, Yosuke Fujita, Mikiko Tomino, and Kiyoshige OhsetoDepartment of Anesthesiology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan

A document by Jifan Liang . Click on the document to view its contents.

Three sequential batch reactors were operated for the enrichment in microbial communities able to store polyhydroxyalkanoates (PHAs) using activated sludge as inoculum. They ran simultaneously under the same operational conditions (organic loading rate, hydraulic and solids retention time, cycle length, C/N ratio) just with the solely difference of the working temperature: psychrophilic (15°C); mesophilic (30°C); and thermophilic (48°C). The microbial communities enriched showed different behaviours in terms of consumption and production rates. In terms of PHA accumulation, the psychrophilic community was able to accumulate an average amount of 17.7 ± 5.7 wt% poly(3-hydroxybutyrate-co-3-hydroxyvalerate) (PHBV); the mesophilic 40.3 ± 7.0 wt% PHBV, and the thermophilic 14.8 ± 0.3 wt% PHBV in dry weight over total solids. The average PHBV production yields for each selected community were 0.41 ± 0.12 Cmmol PHBV/Cmmol VFA at 15°C, 0.64 ± 0.05 Cmmol PHBV/Cmmol VFA at 30°C, and 0.39 ± 0.14 Cmmol PHBV/Cmmol VFA at 48°C. The overall performance of the mesophilic reactor was better than the other two, and the copolymers obtained at this temperature contained a higher PHV fraction. The physico-chemical properties of the obtained biopolymers at each temperature were also measured and major differences were found in the molecular weight, following an increasing trend with temperature.

To understand how semi-arid regions can respond to future climatic changes, it is crucial to understand how they often behave unpredictably regarding water resources. Middle Tapi Basin, an agricultural watershed in India’s central region, was the area of this study, where the SWAT model with a combination of SWATCUP software and the SUFI-2 approach was successfully implemented. This research examined how climate change will affect the basin’s water availability over the following century from 2010 to 2100. Statistically downscaled future projected data for rainfall and temperature for five different CMIP5 models (BNU-ESM, CCCma-CanESM, CNRM-CM5, MPI-ESM-LR, and MPI-ESM-MR) were used for two different RCP scenarios, RCP 4.5 or R1 and RCP 8.5 or R2, and were used. The model performed well for the baseline scenario according to the model performance criteria, ensuring accuracy and future predictability. A monthly analysis of several water balance variables for the baseline and future scenarios similarly revealed a rise in maximum temperature of 5.2% and 9.5% for R1 and R2, respectively, at the end of the century. The contribution of monsoonal rainfall and streamflow during the baseline period was also 89.3% and 90.6%, but for R1 these values tend to decline to 75.2%, and 57.8% and for R2 scenarios 70.8% and 54.7%, respectively. The study shows that less monsoonal rainfall contribution and more extreme rainfall events elevate the basin’s overall water availability. The rise in global temperature results in an increase in evapotranspiration and revaporization at the root zone and thus decreasing the percentage change in surface runoff and groundwater flow in future scenarios. Flow duration curves for all the GCMs and both RCPs gradually increase concerning their corresponding historical values for future periods, indicating increasing water availability in the basin during the close, mid, and distant future scenario.

Echolocation acoustic signature identification is an ideal non-invasive field survey method for chiropteran diversity. Located in the far easternmost region of the Xinjiang Uyghur Autonomous Region where covers one sixth of China’s land territory, Komul city includes a variety of landscapes, including typical mountains, plateaus, plains, and the Gobi Desert, which is home to a number of terrestrial animals. By gathering bat echo sound waves between July and September 2022 and during April 2023, we investigated bat species diversity in Komul, Xinjiang, China. As a result, we identified a total of 24 species of bats belonging to two families and ten genera, of which Myotis is the dominant genus with seven species, followed by Pipistrellus with four species, and both Eptesicus and Nyctalus come after with three species. 16 of these species are novel to Xinjiang. The altitudinal distribution of these species is 500m to 2200m above sea level, and their horizontal distribution includes most of the surveyed region, e.g., Barkol Kazakh Autonomous County, Arturk County, and Ivirghul District. From a conservation perspective, three species (Miniopterus schreibersii、Myotis capaccinii and Nyctalus lasiopterus) and two species (Barbastella barbatellus and Myotis dasycneme) are listed as “vulnerable” and “near threatened” in the IUCN Red List of Threatened Species, respectively. Rest of which are of least concern. Our findings provide a valuable reference for future ecological, genetic, and conservational studies of bats in China, especially in Xinjiang.

Discussed is the case of a 13-year-old male with no significant past medical history, who presented to the hospital for evaluation of multisystem inflammatory syndrome in children (MIS-C). He arrived with findings of conjunctivitis, strawberry tongue, tachycardia at rest, and hypoxemia with oxygen saturation of 85%. The patient was recently hospitalized 1 week prior for viral pneumonia and hypoxemia due to SARS-CoV-2. During his inpatient stay he received combination therapy of remdesivir and dexamethasone. Following, he weaned to room air and his pulse oximetry (SaO2) order was switched to intermittent with floor vitals prior to his discharge.

The movement of animals affects the biodiversity, ecological processes, and resilience of an ecosystem. For the animals, moving has costs as well as benefits and the use of a given landscape provides insights into animal decisions and behavioral ecology. Understanding how animals use the landscape can thus clarify their effects on ecosystems and inform conservation measures aiming at preserving and restoring the ecological functions of animal dispersal. Here, we investigated the habitat preferences of African savanna elephants (Loxodonta africana) using GPS data from 155 individuals collected between 1998 and 2020 in Northern Kenya. In particular, we assessed how “energy landscapes”, i.e. the cost of locomotion due to the slope of the terrain and the animal body mass, together with elevation, vegetation productivity, water availability, and proximity to human settlements influence the habitat preferences of elephants. We found that the energy landscape is the most consistent predictor of elephants’ preferences, with individuals generally avoiding energetically costly areas and preferring highly productive habitats. We also found that other predictors such as elevation, water availability and human presence, are important in determining habitat usage, but varied greatly among elephants, with some individuals preferring habitats avoided by others. Our analysis highlights the importance of the energy landscape as a key driver of habitat preferences of elephants. Importantly, the enerscape modeling environment allowed us to develop testable hypotheses from rather coarse-grained data covering elephant movements and a few environmental parameters. Energy landscapes rely on fundamental biomechanical and physical principles and provide a mechanistic understanding of the observed preference patterns, allowing to disentangle key causal drivers of an animal’s preferences from correlational effects. This, in turn, has important implications for assessing and planning conservation and restoration measures, such as dispersal corridors, by explicitly accounting for the energy costs of moving.

Objective To investigate associations of eating behaviour with symptoms of pelvic floor disorders (PFD), i.e., stress urinary incontinence (SUI), urge urinary incontinence (UUI), faecal incontinence (FI), constipation or defecation difficulties (CDD), and feeling of pelvic organ prolapse (POP) among middle-aged women. Design A cross-sectional, observational study. Setting University Research Laboratory. Sample A population sample of 1 098 Finnish women aged 47 to 55 years. Methods Eating behaviour, demographical, gynaecological, and physical activity variables were assessed using self-report questionnaires. Simple and multiple logistic regression models were used to assess the associations of eating behaviour and symptoms of PFD. Models were adjusted with demographical, gynaecological, and physical activity variables. Main outcome measures Prevalence of symptoms of CDD, FI, POP, SUI, UUI. Results After controlling for confounding, middle-aged women with restrictive eating style were more likely to experience the symptoms of CDD (OR 1.73, CI 1.03–2.90, p=0.039). Women with evening-oriented eating pattern were more likely to experience symptoms of UUI (OR 2.01, CI 1.32–3.07, p=0.001) while maintaining healthy eating patterns was associated with lower risk of UUI (OR 0.45, CI 0.24–0.85, p=0.014) in adjusted models. Conclusions This study provides proof-of-concept evidence to the hypothesis that eating behaviour is associated with perceived pelvic floor disorders, particularly CDD and UUI, warranting further studies to investigate causality.

Objective: To evaluate the association between uterine leiomyoma (UL) and development of type 2 diabetes mellitus in young women using a nationwide database. Design: Nationwide population-based cohort study Setting: South Korea. Population or Sample: Women aged between 20 and 40 years at baseline who underwent at least one health checkup between 2009 and 2012 and followed until December 31, 2018 Methods: We excluded those who were previously diagnosed with type 2 diabetes mellitus (n = 28,136), those diagnosed with type 2 diabetes mellitus within the first year of entry (n = 1,607), those who had hysterectomy during the study period (n = 18,485), and those with missing data (n = 166,012). Cox proportional hazards models were used to analyze the risk of developing type 2 diabetes according to the presence of UL. Main outcome Measures: Incidence of the development of type 2 diabetes mellitus according to the presence of UL Results: 2,755,790 women were selected and he mean age of the enrolled population was 29.70 y, and mean body mass index was 21.31 kg/m 2. Among 2,541,550 participants, 18,375 (0.72%) women had UL. Over a median 7.45 years of follow-up, 23,829 women (0.94%) were diagnosed with type 2 diabetes. The incidence of type 2 diabetes in women with UL (1.805/1,000 person-years) was higher than in those without UL (1.289/1000 person-years). In the multivariable-adjusted model, the hazard ratio for type 2 diabetes in women with UL was 1.216 (95% confidence interval [CI] 1.071-1.382), as compared to those without UL. Compared to women without UL, women with UL who did not undergo myomectomy had a risk 1.328 times (95% CI 1.143-1.542) higher for developing type 2 diabetes. Interestingly, women with UL who underwent myomectomy had no increased risk for developing type 2 diabetes. Conclusions: This study found that young women with UL are more likely to develop type 2 diabetes than those without UL. In addition, myomectomy seemed to attenuate the risk for developing type 2 diabetes in young women with UL.

Membrane-Associated Ring-CH (MARCH) family proteins were recently reported to inhibit viral replication through multiple modes of action. Previous work proved that human MARCH8 blocked Ebola virus (EBOV) glycoprotein (GP) maturation. Our study here demonstrates that human MARCH1 and MARCH2 share a similar pattern to MARCH8 in restricting EBOV GP-mediated viral replication. Human MARCH1 and MARCH2 retain EBOV GP in the trans-Golgi network (TGN), reduce its surface display, and impair EBOV GP-pseudotyped virions infectivity. Furthermore, we uncover that the host proprotein convertase (PC) furin could interact with human MARCH1/2 and EBOV GP intracellularly. Importantly, the furin P domain is confirmed to be recognized by MARCH1/2/8, which is critical for their blocking activities. Besides, bovine MARCH2 and murine MARCH1 also impair EBOV GP proteolytic processing. Altogether, our findings confirm that MARCH1/2 proteins of different species showed a relatively conserved feature in blocking EBOV GP proteolytic processing, which could provide a reference for subsequent antiviral studies and may facilitate the development of novel strategies to antagonize enveloped virus infection.

Case Images

A document by Sarah Baïli. Click on the document to view its contents.

A general reaction norm model of any order can be formulated as a linear mixed model. From this follows that estimates of mean phenotypic traits in a population (fixed effects), and predictions of individual additive genetic deviations from mean reaction norm parameter values (random effects), can be found from the best linear unbiased predictions (BLUP) equation in matrix form. The resulting BLUP model is dynamical in the sense that the incidence matrix varies with time. This leads to a straightforward and multivariate alternative to infinite-dimensional and random regression modeling of reaction norms. Based on such a BLUP model, the within-generation changes in predicted mean reaction norm parameter values can be found by use of the Robertson-Price identity, applied on the predicted random effects. From this follows that the between-generation change in the mean values are found from Robertson’s secondary theorem of natural selection, applied on the predicted random effects. This explains why and to which extent the variances of BLUP random effects are underestimated, which is a well-known observation. The dynamical BLUP model will thus produce the mean reaction norms over time, which makes it possible to disentangle the microevolutionary and plasticity components in for example climate change responses. The BLUP responses will depend on the additive genetic relationship matrix A_t. When A_t is an identity matrix, the results will be identical to the results from a variant of the multivariate breeder’s equation, based on the selection gradient with respect to the individual phenotypic trait values. Parameters are assumed to be known and constant, but it is discussed how they can be estimated by means of a prediction error method. Generations are assumed to be non-overlapping, but adjustments for overlapping generations can easily be done.

Congenital Lobar Emphysema: A diagnostic dilemma with co-existent Congenital Heart Defects

INTRODUCTION:Lichen planus pigmentosus (LPP) was first described by Bhutani et al.1 The lesions are small, brown, oval macules with diffuse borders. Later, they merge to form pigmented areas which are grey or brown. The pigmentation may be diffuse, reticulate, blotchy, or perifollicular. The patches are usually symmetrical in distribution but may be found in a segmental, zosteriform, or blaschkoid pattern.2 CASE REPORT:A 21 year old male, waiter by occupation, hailing from Assam presented to the dermatology OPD with complaints of asymptomatic black discoloration mainly over back, neck, arms, thighs since 4 monthsPatient first noticed brown to black asymptomatic lesion over upper left scapular region which gradually spread to involve the entire back, abdomen, bilateral shoulders, lateral aspect of upper arm, buttocks, thighs and lower legs.There was history of application of mustard oil all over body everyday in the night since 3 years of age. Patient denies any history of long duration of sun exposure or outdoor activities as the lesions were mainly present over the sun protected areas sparing the sun exposed areas and flexural folds.On examination multiple ill defined diffuse hyperpigmentation tending towards symmetry over back, bilateral shoulders, arms, buttocks, thighs and knees was seen. (Figure a-f)There was complete sparing of face, intertriginous areas, forearm, legs, hands, feet , nails , oral and genital mucosa.Histopathological examination shows sparse superficial perivascular lymphocytic infiltrate with numerous melanophages within the papillary dermis. The papillary dermis is slightly thickened and shows delicate fibroplasia and mucin. Overlying epidermis shows focal vacuolar change in the basal layer and infiltration of interface by lymphocytes. The epidermis is flattened at places. The findings were suggestive of Lichen Planus Pigmentosus.(Figure: g-h)