Showing papers in "Journal of Postgraduate Medicine in 2011"

Drug repositioning: re-investigating existing drugs for new therapeutic indications.

Abstract: Drug discovery and development is an expensive, time-consuming, and risky enterprise. In order to accelerate the drug development process with reduced risk of failure and relatively lower costs, pharmaceutical companies have adopted drug repositioning as an alternative. This strategy involves exploration of drugs that have already been approved for treatment of other diseases and/or whose targets have already been discovered. Various techniques including data mining, bioinformatics, and usage of novel screening platforms have been used for identification and screening of potential repositioning candidates. However, challenges in clinical trials and intellectual property issues may be encountered during the repositioning process. Nevertheless, such initiatives not only add value to the portfolio of pharmaceutical companies but also provide an opportunity for academia and government laboratories to develop new and innovative uses of existing drugs for infectious and neglected diseases, especially in emerging countries like India.

Drug-induced Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS-TEN overlap: a multicentric retrospective study.

Abstract: Background : Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare immune-mediated severe cutaneous adverse reactions with incidence rate of 0.05 to 2 persons per million populations per year. Drugs are the most commonly implicated in 95% of cases. Aims : To audit the causative drugs, clinical outcome, and cost of management in SJS, TEN, and SJS-TEN overlap. Setting and Design: Tertiary care hospitals-based multicentric retrospective study (case series). Materials and Methods : Indoor case papers of SJS, TEN, and SJS-TEN overlap admitted between January 2006 and December 2009 in four tertiary care hospitals of Gujarat were scrutinized. Data were collected for demographic information, causative drugs, investigations, treatment given, duration of hospital stay, time interval between onset of symptoms and drug intake, clinical outcome, and complications. Data were analyzed to find out proportion of individual drugs responsible, major complications, and clinical outcome in SJS, TEN, and SJS-TEN overlap. Total cost of management was calculated by using cost of drugs, investigations, and consumables used during entire hospital stay. Statistical Analysis : One-way Analysis of Variance followed by Tukey-Kramer multiple comparison test was used for comparison of incubation period, duration of hospital stay, and cost of management. Results : Antimicrobials (50%), nonsteroidal anti-inflammatory drugs (22.41%), and antiseizure drugs (18.96%) were the most commonly associated groups. Nevirapine (28.12%) was the most common drug. Antiseizure drugs were more often associated with serious form of adverse reaction (TEN: 81.8%) than other drugs. Duration of hospital stay (20.6 vs 9.7 days) and cost of management (Rs 7 910/- vs Rs 2 460/-) were significantly higher in TEN than SJS (P=0.020 and P<0.001, respectively). Time duration between drug intake and onset of symptoms (17.7 vs 27.5 days) was nonsignificantly lower in TEN as compared with SJS. Secondary infection (28.12%) was the most common complication noted. Mortality rate was 15.6% among all cases; 9% in SJS and 26.7% in TEN. Conclusion : Antimicrobial drugs are the most commonly implicated drugs and cost of managing these adverse drug reactions is higher than other serious ADRs.

Clinical uses of the medicinal leech: a practical review.

Abstract: The medicinal leech, Hirudo medicinalis, is an excellent example of the use of invertebrates in the treatment of human disease. Utilized for various medical indications since the ancient times, the medicinal leech is currently being used in a narrow range of well-defined and scientifically-grounded clinical applications. Hirudotherapy is most commonly used in the setting of venous congestion associated with soft tissue replantations and free flap-based reconstructive surgery. This is a comprehensive review of current clinical applications of hirudotherapy, featuring a comprehensive search of all major medical search engines (i.e. PubMed, Google Scholar, ScientificCommons) and other cross-referenced sources. The authors focus on indications, contraindications, practical application/handling of the leech, and therapy-related complications.

Glutathione as an antioxidant in inorganic mercury induced nephrotoxicity.

Abstract: Heavy metal toxicity represents an uncommon but clinically significant medical condition, which if unrecognized or inappropriately treated results in significant morbidity and mortality. Among heavy metals, mercury is recognized as a potent and widely distributed toxicant having the ability to accumulate at various levels of food chain besides possessing ability to cross placental and blood-brain barrier. Symptom picture of mercury (Hg 2+ ) toxicity is characterized mainly by a series of renal disorders. Mechanism of inorganic mercury toxicity includes production of reactive oxygen species (ROS) capable of damaging lipids in membrane, proteins or enzymes in tissues, and DNA to induce oxidative stress as balance between generation, and elimination of ROS is essential for maintaining the functional integrity of a cell. Mitigation of endogenous mercury depends as a part on the presence of antioxidants such as glutathione - most abundant intracellular non-protein thiol that plays a central role in the maintenance of cellular redox status by quenching free radicals generated during oxidative stress. Ability of a cell to survive the threat posed by endogenous mercury represents a biological adaptation fundamental to survival. This review describes the current understanding and the mechanisms involved by different forms of mercury in eliciting their toxicity in kidney along with the knowledge of major intracellular reductant that plays important role in the mitigation of mercury toxicity for the maintenance of homeostasis within the body of living organisms.

Tuberculosis and female reproductive health.

Abstract: Tuberculosis (TB) is an important cause of mortality and morbidity all over the world and is particularly relevant in developing countries like India where the disease is endemic. Female reproductive system is very vulnerable to this infection and clinical presentation of this disease in female reproductive tract is protean in nature and in a large majority of patients could be completely silent. This disease is an important cause of infertility, menstrual irregularity, pregnancy loss, and in association with pregnancy, morbidity to both the mother and child increases. Some of the effects of TB infection on female genital tract could be remote in nature due to infection elsewhere. Medicines used to treat TB infection can also have adverse effects on contraception and other areas of female reproductive health. HIV coinfection and multidrug-resistant tuberculosis (MDR-TB) and increased population migration from developed to developing countries have now added a whole new dimension to this infection. Though new, finer diagnostic tools of detection of TB are increasingly available in the form of bacterial cultures and polymerase chain reaction (PCR) based diagnostics, suspicion by clinicians remains the main tool for diagnosis of the condition. Hence, doctors need to be properly trained to become "Tuberculosis Minded".

Status epilepticus: Why, what, and how

Abstract: Status epilepticus (SE) is an important neurological emergency with high mortality and morbidity. The first official definition of SE was the product of 10 th Marseilles colloquium held in 1962 which was accepted by International League Against Epilepsy in 1964. There are as many types of SE as of seizures. SE is supposed to result from failure of normal mechanisms that terminate an isolated seizure. In half of the cases, there is no history of epilepsy and SE is precipitated by some intercurrent infection. In children, it is often infection, whereas in adults, the major causes are stroke, hypoxia, metabolic derangements, and alcohol intoxication or drug withdrawal. The treatment of SE aims at termination of SE, prevention of seizure recurrence, management of precipitating causes, and the management of complications. The extent of investigations done should be based on the clinical picture and cost benefit analysis. The first line antiepileptic drugs (AED) for SE include benzodiazepines, phenytoin, phosphenytoin, and sodium valproate. Mortality of SE ranges between 7 and 39% and depends on underlying cause and response to AEDs.

Clinical characteristics and outcomes of patients with acute lung injury and ARDS.

Abstract: Background : Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are critical illnesses associated with significant morbidity and mortality. Aims : This was designed to assess various etiologies of ALI/ARDS, to determine the correlation between the diagnostic criteria and need of mechanical ventilation, and to correlate biochemical factors with the outcome of patients. Settings and Design : An observational, prospective study was conducted in a medical intensive care unit (MICU) of a tertiary care hospital, for a period of 1 year. Materials and Methods : This study encompassed 58 consecutive cases of ALI/ARDS admitted to a MICU as per AECC guidelines. Patients excluded were with cardiac failure, chronic kidney diseases with fluid overload, and age below 12 years. Statistical Analysis : The data were analysed applying χ2 -test, multivariate logistic regression analysis of significance, using computer-based program SPSS. Results : There were more males (74%) than females, and presentation was more common in the younger age group, with a total mortality of 57%. Factors attributable for ALI/ARDS were malaria in 16 patients (27.6%), leptospirosis in 12 (20.7%), malaria with dengue in 3 (5.2%), undiagnosed fever in 16 (27.6%), pneumonia in 8 (13.8%), urinary tract infection in 2 (3.4%), and pancreatitis in 1 (1.7%) patient. Out of 41 patients with PaO 2 /FiO 2 200, 11 patients though initially managed on noninvasive ventilation (NIV) subsequently required invasive ventilation, and remaining six were successfully managed on NIV. Out of 41 patients requiring mechanical ventilation, 36 had LIS >2.5, whereas only 3 out of 17 patients with LIS <2.5 required mechanical ventilation. Conclusion : Malaria, leptospirosis, and undiagnosed fever were the main etiologies followed by pneumonia, urinary tract infections, and pancreatitis. Both the PaO 2 /FiO 2 ratio and lung injury score (LIS) at the time of admission were significant predictors of the outcome and of necessity of mechanical ventilation. PaO 2 /FiO 2 was a better predictor of duration of stay at the intensive care unit than the LIS. Sepsis, acidosis, hypotension, and multiorgan failure were individual predictors of mortality in patients with ALI/ARDS while age, sex, anemia, thrombocytopenia, renal failure, hepatic failure, and X-ray picture were not predictors of the outcome.

Frequency and nature of adverse drug reactions in elderly in-patients of two Indian medical college hospitals

Abstract: Background : Adverse drug reactions (ADRs) are a major public health problem in the elderly. Although the Indian elderly represent 12.8% of the entire global elderly population, data on prevalence and predictors of ADRs in elderly Indians is extremely limited. Aim : To determine the prevalence, severity, preventability, length of hospital stays, and risk factors for ADRs in hospitalized Indian elderly. Setting : Medicine wards of two tertiary care teaching hospitals. Design : Prospective study was conducted between July 2007 and December 2009. Materials and Methods : In-patients of either sex and aged ≥60 years were included and monitored for ADRs throughout their hospital stay. Severity (Hartwig et al. scale), preventability (Shumock and Thornton criteria) and increased length of stay (considering underlying disease, ADR, and discussion with clinicians) were assessed. Statistical Analysis : Bivariate analysis and subsequently multivariate logistic regression were used to determine the risk factors for developing ADRs. Results : Over the study period, among the 920 patients monitored, 296 patients (32.2%) experienced 419 ADRs. Among all ADRs, 48.4% (203) were preventable. Majority of ADRs [226 (53.9%)] were moderate in severity. Therapeutic classes of drugs frequently associated with ADRs were the drugs used in diabetes [76 (18.1%)] and antibacterials for systemic use [54 (12.9%)]. ADRs increased the hospital stay in 5.9% (54) of patients. Female gender [Odds Ratio: 1.52, 95% Confidence Interval:1.04-2.22, P=0.03] was observed as the influential risk factor for ADRs. Conclusion : One third of hospitalized elderly experienced ADRs. Interventions focused at preventable ADRs should be developed and implemented to reduce their implications.

High prevalence of tobacco use, alcohol use and overweight in a rural population in Tamil Nadu, India.

Abstract: Background: Cardiovascular diseases are one of the leading causes of death in India. There is high prevalence of cardiovascular risk factors in urban Tamil Nadu. There are limited data on the prevalence of behavioral risk factors and overweight in rural Tamil Nadu. Aim: We estimated prevalence of behavioral risk factors, overweight and central obesity in a rural population in Tamil Nadu, India. Setting and Design: We conducted a cross-sectional survey in 11 villages in Kancheepuram/Thiruvallur districts, Tamil Nadu. Materials and Methods: Study population included 10,500 subjects aged 25-64 years. We collected data on behavioral risk factors and anthropometric measurements. Body mass index (BMI) was categorized using the classification recommended for Asians. Central obesity was defined as waist circumference ≥90 cm for men and ≥80 cm for women. We computed proportions for all risk factors and used trend chi-square to examine trend. Results: Among the 10,500 subjects, 4927 (47%) were males. Among males, 1852 (37.6%) were current smokers and 3073 (62.4%) were current alcohol users. Among females, 840 (15.1%) were smokeless tobacco users. BMI was ≥23.0 kg/m 2 for 1618 (32.8%) males and 2126 (38.2%) females. 867 (17.6%) males and 1323 (23.7%) females were centrally obese. Most commonly used edible oil was palm oil followed by sunflower oil and groundnut oil. Conclusion: We observed high prevalence of tobacco use, alcohol use and central obesity in the rural population in Tamil Nadu. There is need for health promotion programs to encourage adoption of healthy lifestyle and policy interventions to create enabling environment.

Knowledge, attitude and practice of pediatric critical care nurses towards pain: survey in a developing country setting.

Abstract: Background : Nurses' knowledge, sensitivity and attitudes about pain in children and its management affect their response and therefore management of pediatric pain Children in critical care units undergo more painful procedures than those in general wards Aims : To study the knowledge, attitude and practice of nursing personnel catering to critically ill children in a developing country Settings and Design : Prospective questionnaire-based survey Materials and Methods : The survey was carried out in a tertiary care teaching hospital on nursing personnel in three pediatric/neonatal intensive care units The domains studied were: i Training and experience, ii Knowledge of pediatric pain, iii Individual attitude towards pain in children, iv Personal practice(s) for pain alleviation, v Pain assessment, and vi Non-pharmacological measures adopted Statistical Analysis : Descriptive statistics and logistic regression Results : Of the 81 nursing personnel working in the three critical care units, 56 (691%) responded to the questionnaire Only one-third of them had received formal training in pediatric nursing Fifty percent of the respondents felt that infants perceive less pain than adults Training in pediatric nursing was a significant contributing factor in the domain of knowledge (P=003) Restraint and distraction were the common modalities employed to facilitate painful procedures Scientific approaches like eutectic mixture of local anesthetic and the judicious use of sedatives were not adopted routinely Observing a child's face and posture were widely used parameters to assess pain (83%) None of the three critical care areas used a scoring system to assess pain Conclusions : There are several lacunae in the knowledge and practice of nurses in developing countries which need to be improved by training

Obstructive sleep apnea: not just a sleep disorder

Abstract: Obstructive sleep apnea (OSA) has long been recognized as a disorder characterized by snoring and frequent cessations of breathing resulting in fragmentation of sleep, which eventually leads to cumulative sleep debt in affected patients. Until two decades ago, snoring and apneas drew attention mainly as a social curiosity and sleep apnea was not thought of as a serious disorder with multisystem involvement. Impairment of quality of work and high incidence of motor vehicle accidents associated with OSA were recognized toward the end of the last century. Since the turn of this millennium physicians have become increasingly aware of the various cardiovascular complications, metabolic disturbances, and neuropsychologic deficits. It has become very clear in the last decade that patients with OSA have a high recurrence of atrial fibrillation after elective cardioversion if their sleep apnea is not treated with continuous positive airway pressure (CPAP). Poor control of diabetes mellitus and resistant hypertension in the setting of OSA has also been recognized and significant progress in our understanding in this area has been accomplished. Unless physicians include sleep in their system review, many cases will go undiagnosed, which will eventually result in cardiovascular complications. Patients are also not readily forthcoming with the symptoms of sleep apnea, as they often assume that symptoms, such as snoring and daytime sleepiness, are not something serious to be discussed with their physician. In this review, the characteristics, the pathophysiology, and epidemiology of OSA are discussed. Furthermore, the mechanisms by which OSA affects the cardiovascular, endocrine, and metabolic functions have been explored.

A framework for healthcare quality improvement in India: the time is here and now!

Abstract: Healthcare in India has been undergoing rapid changes in the last decade. As demand outpaces supply, quality improvement (QI) initiatives and tools can be beneficial to enhance safe, effective, efficient, equitable and timely care. Healthcare quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. This article discusses the framework for QI and reviews the Plan-Do-Study-Act (PDSA), Lean and Six Sigma methodologies, and briefly discusses key patient safety and quality measurement concepts. The PDSA cycle assists in testing the ideas through small tests of change or "pilots". Six Sigma aims at reducing variations in processes, and the Lean methodology predominantly focuses on enhancing process efficiency and eliminating non-value added steps in the process. It is likely that such structured problem solving approaches will provide an objective and systematic method of enhancing quality in healthcare institutions across India. As increasing attention being is paid on enhancing the quality of life through the Quality Council of India and accreditation of hospitals in India through the International Organization for standardization and National Accreditation Board for hospitals and healthcare providers, a focus on QI by institutional leaders and healthcare providers is key to enhancing the safety and quality of healthcare in India. Central to this also will be leadership buy-in, identification of a core faculty or team that will be the initiators of change, a respect for the need for faculty training and education in QI, measurement of issues to identify key priorities to focus on, and enhanced information systems where resources permit the same.

A meta-analysis of low-dose aspirin for prevention of preeclampsia

Abstract: Background : Low-dose aspirin (LDA) is widely used for prevention of preeclampsia. However, conflicting results have been obtained from various studies. Aim: The aim of our study was to evaluate the effect of LDA in prevention of preeclampsia in high-risk and low-risk women. Materials and Methods : A total of 19 randomized control trials were identified using PUBMED search engine and Cochrane Clinical Trial register. The study population was divided into high-risk and low-risk groups. The effect measured was incidence of preeclampsia in women taking either LDA or placebo where the relative risk (RR) and the 95% confidence interval (CI) were calculated for both groups. Results : A total of 28237 women were studied, out of which 16550 were in the low-risk group while 11687 were in the high-risk group. The overall incidence of preeclampsia was 7.4%. With the aspirin group it was 6.9% while in the placebo group it was 7.8%. In the high-risk group there was 21% reduction in the risk of preeclampsia associated with the use of aspirin (RR 0.79, 95% CI 0.65-0.97). However, LDA is not effective in reducing the risk in low-risk population (RR 0.86, 95% CI 0.64-1.17). Conclusion: LDA has a small effect in the prevention of preeclampsia in women considered to be at high risk for the disease. However, it is not effective in reducing the risk in the low-risk group.

Prevalence of diabetes, obesity, and metabolic syndrome in subjects with and without schizophrenia (CURES-104)

Abstract: Background : There are some reports that diabetes and metabolic syndrome (MS) are more prevalent among schizophrenia patients. However, there are very few studies in India which have estimated the prevalence of diabetes and MS in schizophrenia patients. Aims : The aim of this study was to determine the prevalence of diabetes, obesity, and MS in subjects with and without schizophrenia. Settings and Design : This case control study comprised of cases i.e. subjects with schizophrenia recruited from a schizophrenia centre at Chennai and controls i.e. healthy age- and gender-matched subjects without psychiatric illness selected from an ongoing epidemiological study in Chennai in a 1:4 ratio of cases: Controls. Materials and Methods : Fasting plasma glucose and serum lipids were estimated for all subjects. Anthropometric measures including height, weight, and waist circumference were assessed. Diabetes and impaired fasting glucose (IFG) were defined using American Diabetes Association criteria. Statistical analysis : One-way ANOVA or student's t test was used to compare continuous variables and Chi-square test to compare proportion between two groups. Results : The study group comprised of 655 subjects, 131 with schizophrenia and a control group of 524 subjects without schizophrenia. The prevalence of the diabetes, IFG, abdominal obesity and MS were significantly higher among subjects with schizophrenia compared to those without schizophrenia-diabetes (15.3% vs. 7.3%, P=0.003), IFG (31.3% vs. 8.6%, P<0.001), abdominal obesity (59.2% vs. 44.7%, P<0.001), and MS (34.4% vs. 24%, P=0.014). Conclusion : In subjects with schizophrenia, the prevalence of diabetes, IFG, abdominal obesity, and MS is significantly higher than in those without schizophrenia.

Statin intolerance: now a solved problem.

Abstract: Statins are the most effective and widely used drugs for treating dyslipidemia, a major risk factor for coronary heart disease. These are one of the safest hypolipidemic drugs but many patients are bound to discontinue statins due to their side effects. Hepatotoxicity, myotoxicity and peripheral neuropathy are important out of them. Discontinuation of statins leads to dylipidemia and its grave consequences. Hence, there should be enough strategies for statin intolerant patients, so that they can be saved from these consequences. These side effects can be avoided by the awareness of certain factors viz. potential drug interactions and dose adjustment according to patho-physiology of the patient. Baseline investigations for liver function and muscle toxicity should be done before initiating statin therapy. Here, we are discussing various options for statin intolerant hyperlipidemic patients such as lower and intermittent dosing of statins, alternate hypolipidemic drugs, red yeast rice, supplementation with coenzyme Q10 and vitamin D. A number of hypolipidemic drugs are in trial phases and hold promise for statin intolerant patients.

A study of drug-drug interactions in cancer patients of a south Indian tertiary care teaching hospital

Abstract: Background : Drug interactions in oncology are of particular importance owing to the narrow therapeutic index and the inherent toxicity of anticancer agents. Interactions with other medications can cause small change in pharmacokinetics or pharmacodynamics of chemotherapeutic agents that could significantly alter their safety and efficacy. Aim : To identify and document the potential drug-drug interactions in prescriptions of patients receiving cancer chemotherapy. Settings and Design : A tertiary care teaching hospital based prospective study. Materials and Methods : Patients admitted in the medical oncology wards with different types of malignancies and receiving cancer chemotherapy during the period of June 2009 to November 2009 were included in the study. A detailed data collection was done in a specially designed proforma with ethical approval and consent of patients and their prescriptions were subjected to drug-drug interaction screening using Drug Interaction Fact Software Version-4 and standard references. Incidence of drug-drug interactions, their types, correlation between age, cancer type, number of drugs prescribed and incidence of drug interactions were analyzed. Statistical Analysis : Logistic regression analysis and Odds ratio were performed to identify the incidence of drug-drug interactions and their correlation with the factors above mentioned. Results : A total of 75 patients (32 males and 43 females; median age 56 years, age range 23-74) were enrolled in the study and their prescriptions were screened. 213 interactions were identified of which, 21 were major, 121 were moderate and 71 were minor. There were 13 (6.1%) clinically significant interactions between anticancer drugs and 14 (6.5%) drug-drug interactions between anticancer drugs and other drugs prescribed for co-morbidities. There was a positive correlation between number of drugs prescribed and drug interactions (P=0.011; OR 0.903). Conclusion : Though there was not any life threatening interactions, the potential interactions were brought to the oncologist purview for ensuring patients safety and to avoid undesirable effects.

Management of nonvariceal upper gastrointestinal bleeding

Abstract: Nonvariceal upper gastrointestinal bleeding is unique from variceal bleeding in terms of patient characteristics, management, rebleeding rates, and prognosis, and should be managed differently. The majority of nonvariceal upper gastrointestinal bleeds will not rebleed once treated successfully. The incidence is 80 to 90% of all upper gastrointestinal bleeds and the mortality is between 5 to 10%. The causes include nonacid-related ulceration from tumors, infections, inflammatory disease, Mallory-Weiss tears, erosions, esophagitis, dieulafoy lesions, angiodysplasias, gastric antral vascular ectasia, and portal hypertensive gastropathy. Rarer causes include hemobilia, hemosuccus pancreaticus, and aortoenteric fistulas. Hematemesis and melena are the key features of bleeding from the upper gastrointestinal tract, but fresh per rectal bleeding may be present in a rapidly bleeding lesion. Resuscitation and stabilization before endoscopy leads to improved outcomes. Fluid resuscitation is essential to avoid hypotension. Though widely practiced, there is currently insufficient evidence to show that routine red cell transfusion is beneficial. Coagulopathy requires correction, but the optimal international normalized ratio has not been determined yet. Risk stratification scores such as the Rockall and Glasgow-Blatchford scores are useful to predict rebleeding, mortality, and to determine the urgency of endoscopy. Evidence suggests that high-dose proton pump inhibitors (PPI) should be given as an infusion before endoscopy. If patients are intolerant of PPIs, histamine-2 receptor antagonists can be given, although their acid suppression is inferior. Endoscopic therapy includes thermal methods such as coaptive coagulation, argon plasma coagulation, and hemostatic clips. Four quadrant epinephrine injections combined with either thermal therapy or clipping reduces mortality. In hypoxic patients, endoscopy masks allow high-flow oxygen during upper gastrointestinal endoscopy. The risk of rebleeding reduces after 72 hours. In rebleeding, repeat endoscopy is useful and persistent failure of endoscopic therapy mandates either embolization or surgery. In this review, we analyze the management of nonvariceal upper gastrointestinal bleeding with evidence from the currently published clinical trials.

Surgery in Hashimoto's thyroiditis: indications, complications, and associated cancers.

Abstract: Background : Indications for surgery in Hashimoto's thyroiditis (HT) patients are compressive symptoms and suspicion of malignancy. A high incidence of thyroid malignancy has been reported in patients with HT. The effect of surgery on discomfort in swallowing and tightness in the neck has not been properly evaluated. Aims: The aim of our study is to compare the indications, complications, and associated cancers in patients operated for HT with those surgically treated for other benign goitres. The effect of surgery on minor symptoms like tightness in the neck and discomfort in swallowing is included. Setting and Design : This was a retrospective case-control study at a tertiary care centre. Patients and Methods : A total of 271 patients who had undergone surgery for benign thyroid diseases were included. Group A consisted of 35 patients who had HT and Group B consisted of patients operated for other benign thyroid diseases (236 patients). Statistical Analysis : Data were analyzed using SPSS 12 software. Independent group's t-test was used to compare the means and Fisher's exact test was used for categorical data. Results : In Group A, the common indications for surgery were discomfort associated with swelling (45.7%), cosmesis (34.3%), and pain with swelling (11.4%) whereas in Group B, the indication was predominantly cosmetic (80%). A total of 22.9% patients of Group A and 6% of Group B were hyperthyroid. The sensitivity of FNAC for diagnosing thyroiditis was 62.8% (n = 22). Postoperative complication rates were similar in both the groups. The mean operating time was higher in Group A even though the gland was smaller. Incidental malignancy was 3.4% in Group B whereas there was none in Group A. Discomfort in swallowing and tightness in the neck were relieved at 3 months after surgery. Conclusions : Large, euthyroid and apparently asymptomatic HT occasionally need surgical intervention. Discomfort in swallowing and tightness in the neck are relieved after surgery. Thyroidectomy is safe to perform and has a low incidence of permanent complications. There was no associated malignancy in our series of HT.

Evaluation of eperisone hydrochloride in the treatment of acute musculoskeletal spasm associated with low back pain: a randomized, double-blind, placebo-controlled trial.

Abstract: Background : Eperisone hydrochloride is a centrally acting muscle relaxant inhibiting the pain reflex pathway, having a vasodilator effect. Aims : To evaluate the efficacy and tolerability of eperisone in patients with acute musculoskeletal spasm associated with low back pain. Settings and Design : Prospective, randomized, double-blind, placebo-controlled, multicentric trial conducted at five tertiary care orthopedic centers across India. Materials and Methods : It was planned to enroll 240 patients of either sex between 18-60 years with acute musculoskeletal spasm (AMSP) with low back pain (LBP) due to spondylosis deformans, prolapsed disc or muscle sprain. Patients with other associated unrelated spasm conditions were excluded. Assessments were done for finger-to-floor distance (FFD), lumbar pain, Lasegue's sign, tenderness of vertebral muscles, need for rescue medication and response to therapy for efficacy and tolerability. Statistical Analysis : Parametric data were analyzed by 't' test and ANOVA, and non-parametric data were analyzed using Mann-Whitney 'U' test and Kruskall-Wallis test. Proportions were compared using Fischer's (Chi-square) test. Results : Two hundred and forty patients were randomized to receive eperisone 150 mg/day in three divided doses (n=120) or placebo (n=120) for 14 days, of which 15 patients did not complete and 225 patients completed the study (eperisone, 112 and placebo, 113). Significantly greater improvement in FFD (P<0.001) from baseline on Day 14 was seen with eperisone (150.66 to 41.75) compared to placebo (138.51 to 101.60). Improvements in other parameters were greater with the eperisone group. For 89 (79.46%) patients the therapy was rated as good-excellent with eperisone compared to 43 (38.05%) patients with placebo. Nausea, abdominal pain, headache and dizziness were the common adverse events with both therapies. Rescue drug was needed by 40 (35.71%) eperisone patients and 83 (73.45%) placebo patients. Conclusions : Eperisone hydrochloride was effective and well tolerated for the treatment of patients with AMSP with LBP.

Diabetes insipidus as the first symptom caused by lung cancer metastasis to the pituitary glands: Clinical presentations, diagnosis, and management

Abstract: Background : Central diabetes insipidus (CDI), secondary to pituitary metastatic lesions, is uncommon; however, lung and breast cancer are the commonest malignancies to have metastases to the pituitary. Early management of systemic chemotherapy and pituitary irradiation might improve the prognosis of patients. Aims : To investigate the clinical features, diagnosis, and management of CDI caused by lung cancer metastasis to the pituitary glands. Materials and Methods : We retrospectively reviewed 10 patients who had CDI as their first symptom before their lung cancers were diagnosed. Their clinical presentations, anterior pituitary gland function, sellar magnetic resonance imaging (MRI), management, and prognosis were described. Settings and Design : This retrospective cross-sectional clinical study was conducted in a medical college hospital. Results : The patient's mean age was 58.6±7.8 years. Diabetes insipidus was the main complaint when they were referred to our hospital. MRI revealed specific dumbbell-shaped masses in the sella turcica in five patients. In seven patients whose hormones were measured, the levels of hormones from adenohypophysis were abnormally low in six patients. The main treatments included surgery, systemic chemotherapy, and sellar irradiation. Although nine patients had poor prognoses, one patient has survived for more than 3 years, suggesting benefit from early diagnosis and treatment. Conclusions : New-onset CDI might be the only symptom presented by the patients with pituitary metastasis (PM) from lung cancer. Dumbbell-shaped sellar masses in MRI are prone to the diagnosis of PM. A thorough examination for primary cancer should be carried out in these aged and elderly patients.

Neuralgic amyotrophy associated with dengue fever: case series of three patients.

Abstract: Dengue is an acute mosquito borne viral infection caused by one of the four distinct serotype of dengue viruses (type 1-4), belonging to flavivirus family. Dengue fever, an arboviral infection is known to cause various neurological complications. Commonly reported neurological manifestations associated with dengue infection are encephalopathy, myelopathy, stroke, Guillain-Barre syndrome and hypokalemic paralysis. Brachial amyotrophy associated with dengue infection were not described previously. Here, we describe three patients presenting with brachial neuritis associated with dengue infection. Dengue infection should be considered in the etiological list of brachial neuritis in dengue endemic areas, especially if preceded by history of febrile illness compatible with dengue illness.

Idiopathic pulmonary hemosiderosis: alveoli are an answer to anemia.

Abstract: Idiopathic pulmonary hemosiderosis (IPH) is a rare disorder (triad of iron-deficiency anemia, hemoptysis, and alveolar infiltrates). A 3-year-old male presented with mild fever, breathlessness, dry cough, and bluish nail discoloration for 8 days. He had required five blood transfusions in the past 1 year (last transfusion was given 4 months ago). He had a respiratory rate of 58/min with respiratory distress, cyanosis, and grade III clubbing. Respiratory system examination was normal. Several previous reports of hemoglobin were as low as 3.6 g/dl with hypochromic and microcytic anemia. There were transient increases in the hemoglobin and normalization of red cell morphology with blood transfusions. Serum iron, G6PD enzyme assay, hemoglobin electrophoresis, the sickling test, Coomb's test, stool and urine analysis, and a Meckel's scan were normal. HIV antibody and dsDNA were negative. The chest radiograph revealed symmetrical patchy infiltrates sparing lung apices (confirmed on high-resolution computed tomography). Lung biopsy diagnosed pulmonary hemosiderosis (interstitial lung disease with hemosiderin-laden macrophages scattered in the alveoli and areas of fibrosis in the alveolar septa). The patient showed marked clinical improvement in 10 days of therapy with prednisolone. IPH should be listed in the differential diagnosis of a child presenting with unexplained hypochromic, microcytic anemia and respiratory symptoms.

Impact of parenting practices on parent-child relationships in children with specific learning disability.

Abstract: Background: Parents of children with specific learning disability (SpLD) undergo stress in coping up with their child's condition. Aims: To document the parenting practices of parents having a child with newly diagnosed SpLD and to analyze their impact on parent-child relationships. Settings and Design: Cross-sectional questionnaire-based study in our clinic. Materials and Methods: From May 2007 to January 2008, 150 parents (either mother or father) of children consecutively diagnosed as having SpLD were enrolled. Parenting practices and parent-child relationships were measured by the Alabama Parenting Questionnaire-Parent Form (APQ-PF) and the Parent Child Relationship Questionnaire (PCRQ), respectively. Statistical Analysis Used: Pearson correlation coefficients between subscales of APQ-PF and PCRQ were computed. Multiple regression analysis was carried out for statistical significance of the clinical and demographic variables. Results: Parents who were: (i) involved in parenting had a good personal relationship and disciplinary warmth, (ii) practicing positive parenting had good warmth, personal relationship and disciplinary warmth, (iii) poorly supervising their child's activities lacked warmth and personal relationship, (iv) practicing inconsistent discipline' had a higher power assertion and (v) practicing corporal punishment lacked warmth and had a higher power assertion and possessiveness in their relationships with their child. Parent being poorly educated or currently ill and child having all three types of SpLD present concomitantly or a sibling or a sibling with a chronic disability or being in class standard IX to XI were variables that independently predicted a poor parenting or parent-child relationship subscale score. Conclusions: The present study has identified parenting practices that need to be encouraged or excluded for improving parent-child relationships. Initiating these measures would help in the rehabilitation of children with SpLD.

Salutary effect of parathyroidectomy on neuropsychiatric symptoms in patients with primary hyperparathyroidism: evaluation using PAS and SF-36v2 scoring systems.

Abstract: Background : Indian patients with primary hyperparathyroidism (pHPT) usually present with a triad of advanced disease of bones, stones, and psychic moans. There are hardly any reports from India on the outcome of successful parathyroidectomy on psychiatric symptoms. Aims : To evaluate the outcome of parathyroidectomy on psychiatric symptoms in Indian patients with advanced pHPT. Settings and Design : Prospective study done in a tertiary care super-specialty hospital in northern India. Materials and Methods : Health surveys using parathyroid assessment of symptom score (PAS) and SF-36v2 were carried out, to evaluate the outcome of parathyroidectomy on the psychiatric symptoms of patients. The study included 42 patients of pHPT admitted between November 2007 and December 2009 (two years). Scoring was done preoperatively; and one week, three months, six months, and one year postoperatively. Statistical Analysis Used : SPSS 15 software and nonparametric tests (k Independent Sample test, Kruskal-Wallis H). Results : The mean preoperative PAS score was 430.87 ± 215.61 (range 40 - 880). Statistically significant reduction in scoring was observed postoperatively at one week (293.65 ± 118.31, P < 0.001), three months (109.44 ± 85.09, P < 0.015), six months (70.00 ± 71.65, P 1 < 0.05), and one year (60.10 ± 104.48, P < 0.02). Although the surgery scores for feeling irritability, forgetfulness, difficulty in getting out of chair, headache, and itchy skin did not reduce appreciably at one week, they later showed significant reduction. All other parameters showed significant reduction. The SF-36v2 TM survey also showed significant improvement on all scores except social functioning, while physical functioning improved only after one week. Conclusions : Indian patients with advanced pHPT, after a successful parathyroidectomy, showed significant improvement in their quality of life, as evaluated by the PAS and SF-36v2 systems.

Anterior abdominal wall abscess with epididymo-orchitis: an unusual presentation of acute pancreatitis.

Abstract: Pancreatitis indicates inflammation of the pancreas. Clinically acute pancreatitis typically presents as upper abdominal pain mostly in epigastric region, nausea, vomiting and elevated levels of amylase and lipase. Depending upon severity of acute pancreatitis patient may presents with minimal symptoms to more severe signs of acute abdomen like generalized guarding and rigidity. Inspite of absence of disease-specific signs and symptoms for acute pancreatitis, diagnosis is usually not difficult using a combination of clinical, laboratory and radiological findings. Sometimes pancreatitis may presents atypically, which may be misleading in the management especially when typical presentation of pancreatitis as described above is absent. We have described a case of pancreatitis where patient presented with anterior abdominal wall abscess with epididymo-orchitis because of tracking of pancreatic fluid into the retroperitoneum till scrotum. Patients presentation may be different depending upon complication occurred during the course of pancreatitis. After reviewing the literature we found very few cases in which you may not get a clue to diagnose pancreatitis because of atypical presentation. In the described case, patient managed conservatively with percutaneous drainage of the abscess by pigtail catheter placement and scrotal support for epididymoorchitis. This avoided unnecessary exploration in above patient.

The obstetric outcome following treatment in a cohort of patients with antiphospholipid antibody syndrome in a tertiary care center.

Abstract: Background: Antiphospholipid antibody syndrome (APAS) is regarded as the most frequently acquired risk factor for thrombophilia. The obstetric manifestations of APAS include early or late pregnancy losses and complications like preeclampsia and fetal growth restriction. Its timely diagnosis and treatment can improve maternal and neonatal outcome. Aims: To study the pregnancy outcome of patients with APAS treated with heparin and aspirin. Settings and Design: This was a retrospective study of pregnancy outcome in 42 consecutive women with APAS, treated with heparin and aspirin. Materials and Methods: The case records of 42 diagnosed cases of APAS with pregnancy, over a 3-year period, were studied. The pregnancy outcome in this group was compared before and after treatment with heparin and low-dose aspirin in terms of abortions, intrauterine deaths and live birth rate. The outcome of the present pregnancy in terms of fetal and maternal complications was analyzed. Results: The mean age and average parity of women with APAS were 30.1±4.1 years and 3.2±1.2, respectively. Among the treated patients of APAS, 13 (30.9%) had preeclampsia and 9 (21.4%) had intrauterine growth restriction (IUGR). There were 2 (4.7%) intrauterine deaths, 4 (9.5%) missed abortions and 3 (7.1%) abruptio placentae. Women with APAS had a live birth rate of 4.6% before treatment and 85.7% in the index pregnancy after treatment. Conclusion: Treatment of pregnant women with APAS results in marked improvement in the live birth rate (4.6-85.7%). However, complications like preeclampsia and IUGR occur even after treatment, requiring strict monitoring and timely delivery.

Pneumococcal infections and immunization in diabetic patients

Abstract: India is today facing a diabetes epidemic and has the maximum number of patients with diabetes in the world. People with diabetes are more prone to develop all types of infections. Pneumococcal infections are a common cause of morbidity and mortality, and people with diabetes are more prone to develop pneumococcal infections. With the availability of the pneumococcal vaccine, most international organizations now recommend that people with diabetes should be vaccinated against pneumococcal disease. This article tries to provide a balanced review of the place of pneumococcal vaccination in Indian diabetic patients.

Resistance pattern in drug-resistant pulmonary tuberculosis.

Abstract: Background : Drug-resistant tuberculosis is an important issue for public health. There is a rise in the trend of drug-resistant tuberculosis, especially multi drug resistance (MDR), in different parts of world, India being one of the high burden countries. This study is undertaken to assess the various patterns of resistance among confirmed drug resistant pulmonary tubercular patients and to initiate second line anti tubercular treatment. Aims and Objectives : To assess various resistance patterns among confirmed drug resistant pulmonary tubercular patients and for the initiation of appropriate drug regimens in our setup. Study Design : An observational prospective study. Materials and Methods : This study was conducted at Rajiv Gandhi Institute of Chest Diseases, Bangalore between January 2005 and November 2010. A total of 309 drug resistant tuberculosis cases were studied. Sputum culture and drug sensitivity were carried out at National Tuberculosis Institute. Drug sensitivity testing done for all first line drugs, except pyrazinamide, by using LJ media. Results : In this study, out of 309 patients, MDR pattern was observed in 224 (72%), of which 20 (6.47%) had resistance only to isoniazid (INH) and rifampicin (RMP), 58 (18.7%) had resistance to INH, RMP, and either of the other first line drugs streptomycinor ethambutol and 146 (47.25%) had resistance to all first line drugs. Poly drug resistance pattern was observed in 72 (23.3%) and Mono drug resistance in 13 (4.2%). Conclusion : In the present study the most common pattern observed is MDR with predominant resistance to INH. There is a rise in the number of drug resistant tuberculosis cases, especially MDR. Hence close monitoring of drug resistant pattern is required to formulate designs of different regimens in the treatment of drug resistant tuberculosis; especially MDR-TB based on accredited laboratory reports, in a specialized center which is very much essential for the betterment of the patients and the community.

Relationship of body fat with insulin resistance and cardiometabolic risk factors among normal glucose-tolerant subjects.

Abstract: Background : The amount of body fat, rather than the amount of excess weight, determines the health risks of obesity, type 2 diabetes mellitus, and cardiovascular disease. Aims : To look at the association of body fat percentage with cardiometabolic risk factors in subjects with normal glucose tolerance (NGT). Settings and Design : Cross-section study from the Chennai Urban Rural Epidemiology Study. Materials and Methods : Body fat was measured by Beurer body fat analyzer. Metabolic syndrome (MS) was diagnosed based on modified ATPIII guidelines. Statistical Analysis : Student's t test or one-way ANOVA (with Tukey's HSD) was used to compare groups for continuous variables. Results : Body mass index, waist circumference, systolic and diastolic blood pressure, HOMA IR, serum cholesterol, and LDL cholesterol increased significantly with increasing tertiles of body fat (P<0.001). There was a linear increase in the percentage of body fat with increase in number of components of MS (no metabolic abnormality: 25±11, one metabolic abnormality: 28±10, two metabolic abnormalities: 33±8, and three and more metabolic abnormalities: 35±7) (P<0.001). Regression models showed significant association of body fat with MS after adjusting for age, gender, insulin resistance, and glycated hemoglobin (Odds ratio: 1.04, 95% confidence interval: 1.04 - 1.08, P<0.001). In linear regression analysis, body fat showed a significant association with insulin resistance after adjusting for age, gender, and glycated hemoglobin (β=0.030, P<0.001). Conclusions : A significant association exists between body fat, MS, and cardiometabolic risk factors even among subjects with NGT.