Showing papers in "Journal of Postgraduate Medicine in 2013"

Association of B12 deficiency and clinical neuropathy with metformin use in type 2 diabetes patients

Abstract: Context: Long-term metformin use has been hypothesized to cause B12 deficiency and neuropathy in Type 2 diabetes patients. However, there is a paucity of Indian data regarding the same. Aim: To compare the prevalence of B12 deficiency and peripheral neuropathy in patients with Type 2 diabetes mellitus treated with or without metformin. Materials and Methods: We recruited patients with Type 2 diabetes and divided them into metformin exposed and nonmetformin exposed groups. We measured baseline demographic variables like age, sex, vegetarian status, and HbA1c levels in both groups. We compared vitamin B12 levels and severity of peripheral neuropathy (using Toronto Clinical Scoring System (TCSS)) in both groups. Definite B12 deficiency was defined as B12 <150 pg/ml and possible B12 deficiency as <220 pg/ml. The difference in vitamin B12 levels and TCSS was calculated in both groups using independent samples t-test. Spearman's rank correlation between cumulative metformin use and B12 level was calculated. Odds ratio of vitamin B12 deficiency in metformin exposed group was also estimated. Results: Mean serum B12 levels was significantly lower in metformin exposed group (n=84) compared with nonmetformin exposed group (n=52) (410±230.7 versus 549.2±244.7, P=0.0011). Mean neuropathy score was significantly higher in metformin exposed group. (5.72±2.04 versus 4.62±2.12, P=0.0064). Odds ratio for possible B12 deficiency was 4.45 (95% CI 1.24-15.97). There was significant negative correlation between cumulative metformin dose and vitamin B12 level (r=−0.68, P<0.0001). Conclusion: Metformin use is associated with vitamin B12 deficiency and clinical neuropathy in Type 2 diabetes patients.

Eschar in scrub typhus: a valuable clue to the diagnosis.

Abstract: Background: Scrub typhus is an acute febrile illness widely prevalent in the 'tsutsugamushi triangle' region of the world. Clinical features include fever, myalgia, headache, rash, and a pathognomonic eschar. An eschar is formed by the bite of chigger mite that inoculates the causative agent of Scrub typhus Orientia tsutsugamushi. The aim of this study is to determine the most common sites of eschars over the bodies of patients with Scrub typhus. Materials and Methods: In a retrospective analysis, we examined a total of 418 patients who presented to Christian Medical College, Vellore between 2009 and 2012 with an acute febrile illness and an eschar on clinical examination and confirmed to have scrub typhus with a positive Scrub typhus IgM ELISA test. We studied the distribution of eschars over the bodies of 418 patients with Scrub typhus. Results: There was a significant difference in the distribution of eschars between males and females with a preponderance of the chest and abdomen (42.3%) among females and the axilla, groin and genitalia (55.8%) in males. Some unusual sites of an eschar were the cheek, ear lobe and dorsum of the feet. Conclusion: The eschar is the most useful diagnostic clue in patients with acute febrile illness in areas endemic for Scrub typhus and therefore should be thoroughly examined for its presence especially over the covered areas such as the groin, genitalia, infra-mammary area and axilla.

Colistin: re-emergence of the 'forgotten' antimicrobial agent.

Abstract: The treatment of the emerging multidrug resistant (MDR) gram-negative organisms is a challenge. The development of newer antibiotics has recently slowed down. This has led to the re-emergence of the 'old forgotten' antibiotic "Colistin", whose use had almost stopped (after 1970's) due to the high incidence of nephrotoxicity and neurotoxicity. Colistin (polymyxin E) is a polypeptide antibiotic belonging to polymyxin group of antibiotics with activity mainly against the gram-negative organisms. Use of colistin has been increasing in the recent past and newer studies have shown lesser toxicity and good efficacy. Colistin acts on the bacterial cell membrane resulting in increased cell permeability and cell lysis. Colistin can be administered orally, topically, by inhalational route, intramuscularly, intrathecally, and also intravenously. Parenteral Colistin (in the form of colistimethate sodium) has been used to treat ventilator-associated pneumonia (VAP) and bacteremia caused by MDR bacteria such as Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii. Inhaled Colistin is used for treating pneumonia/VAP due to MDR gram-negative organisms and also used prophylactically in patients with cystic fibrosis. This manuscript is a brief review of Colistin and its clinical applications in the pediatric population.

Current status of understanding of the genetic etiology of coronary heart disease

Abstract: Coronary heart disease (CHD), synonymously known as coronary artery disease (CAD) is the most predominant among the cardiovascular diseases and ranked number one in prevalence among the developing countries. CHD is a multifactorial disease involving both genetic and environmental factors and is primarily caused due to a process of progressive damage of coronary arteries called atherosclerosis. We present here a comprehensive review of molecular genetic studies conducted so far on CAD. The information was gathered through the internet using appropriate search terms for CHD/CAD. We also compiled the relevant information from the following websites: http://www.bioguo.org/CADgene/and http://www.genome.gov. Besides several Mendelian forms of the CHD, ~300 more genes have been identified in different studies through candidate gene approach. Additionally 32 more loci have been identified through genome wide association studies that include 9p21.3 as the most replicated genetic locus across the globe. Nevertheless, overall, these studies have been characterized by a relative lack of consistency in the association pattern across the populations. A fair degree of ethnic variation in the nature of association of different genetic variants with the disease has also been apparent. Pleiotropic effects of genes, existence of subclinical phenotypes and genetic heterogeneity appear to have been the limiting factors for developing a genetic risk profile test for the disease. Given the high prevalence of this disease in India, the presence of environmental triggers and genetic variation, it would be prudent to conduct multi-ethnic large-scale studies in India, representing the subcontinent as a whole-there have been a very limited number of molecular genetic studies on Indian populations.

Changing trends in the management of hypotension following spinal anesthesia in cesarean section

Abstract: Hypotension during cesarean section under spinal anesthesia remains a frequent scenario in obstetric practice. A number of factors play a role in altering the incidence and severity of hypotension. Counteracting aortocaval compression does not significantly prevent hypotension in most singleton pregnancies. Intravenous crystalloid pre-hydration is not very efficient. Thus, the focus has changed toward co-hydration and use of colloids. Among vasopressors, phenylephrine is now established as a first line drug, although there is limited data in high-risk patients. Though ephedrine crosses the placenta more than phenylephrine and can possibly cause alterations in the fetal physiology, it has not been shown to affect the fetal Apgar or neurobehavioral scores.

Global patterns of seasonal variation in gastrointestinal diseases.

Abstract: Objectives: This study reviewed previous studies to explore the global patterns of seasonal variation in gastrointestinal diseases. Study Design and Methods: A series of systematic literature reviews were undertaken to identify studies reporting seasonal and monthly data on clinical onset or relapse of gastrointestinal diseases (Acute pancreatitis, inflammatory bowel disease, Peptic ulcer diseases (PUD), gastroesophageal reflux disease, colon cancer and colonic diverticulitis). Thirty-two primary studies (published 1970-2012) from 17 countries were identified. Results: Upon review of the evidence, it appears that the seasonal peaks of PUD are most prominent in colder months while the peak of incidence rate of Crohn diseases in most of the countries subjects were found during the spring and summer seasons. Seasonal trend in the onset of acute pancreatitis exhibits a summer peak in some countries. There were no clearly seasonal peaks noted for the ulcerative colitis. Conclusions: Future experimental and observational studies should consider how the environmental factors (infection, cold, air pollution etc.) or other triggers (dietary habit, alcohol consumption) promotes or hinders such diseases.

Oral paracetamol in treatment of closure of patent ductus arteriosus in preterm neonates.

Abstract: We herewith report a case series of six premature neonates with hemodynamically significant paten ductus successfully treated with oral paracetamol. This is a first case series describing the use of oral paracetamol treatment patent ductus in preterm neonates from India. Further prospective randomized-controlled trials are needed to evaluate the efficacy and safety of oral paracetamol in the treatment of patent ductus in preterm neonates.

Risk factors for delirium and inpatient mortality with delirium

Abstract: Background: There is limited on the risk factors and mortality in patients with delirium from India. Aim: This study aimed to evaluate the risk factors associated with delirium and inpatient mortality rates of patients diagnosed with delirium by psychiatry consultation liaison services. Materials and Methods: Three hundred and thirty-one patients diagnosed as delirium by the psychiatry consultation liaison services were examined on standardized instruments: Delirium Rating Scale Revised 98 version (DRS-R-98), amended Delirium Motor Symptom Scale (DMSS), Delirium Etiology Checklist (DEC), Charlson Comorbidity index, and a checklist for assessment of risk factors. Results: More than three medications as a risk factor and metabolic/endocrine disturbances as cause were observed to play largest role in development of delirium. The inpatient mortality rate was 12.4%. Compared to the survivor group, those who died were more likely to be young (<65 years), had significantly high rate of alcohol dependence and were more frequently restrained prior to development of delirium; of these only age <65 years and use of restraints emerged as the significant predictors of mortality in regression analysis. Conclusion: Age and use of restraints appears to be an important predictor mortality in patients with delirium.

"DREEM" comes true - Students' perceptions of educational environment in an Indian medical school.

Abstract: Background: The accomplishment and contentment of students depends upon their educational environment. Very few studies in India have looked at the impact of educational environment on students, there are few such studies in our country despite having a large number of medical schools. Objective: This study was performed to assess the undergraduate students' perceptions of medical education in general and educational environment in our medical school in particular. Materials and Methods: The Dundee Ready Education Environment Measure (DREEM), a validated inventory was distributed among undergraduate students in final Bachelor of Medicine and Bachelor of Surgery (MBBS) (2010-2011) and students who were undergoing internship (2010-2011) and various scores were calculated and the means were compared using Mann-Whitney test. Results: The mean total DREEM score was found to be 121.5/200 for final MBBS students ( n = 115) and 118.4/200 ( n = 109) for the internship batch students. There was no statistically significant difference between the scores of the two batches. The overall DREEM score for our Medical School during the academic year 2010-2011 (for the final MBBS and internship batch) was 120/200 ( n = 224), which showed that the students' perceptions were more positive. Conclusion: The study showed that the students' perception of the educational environment was positive. There was no statistically significant difference between the scores of the two batches (final MBBS and internship). This study helped us to introspect and identify remediable areas in the educational environment of our medical school and hence we could suggest some measures to modify them.

Post total thyroidectomy hypocalcemia: A novel multi-factorial scoring system to enable its prediction to facilitate an early discharge

Abstract: Context: No single factor can predict the occurrence of post total thyroidectomy (TT) hypocalcemia. Aims: This study was conducted to look at various factors usually implicated in post TT clinically significant hypocalcemia (CSH) and to develop a scoring system using a combination of these factors to predict CSH. Settings and Design: Prospective study, tertiary care center. Materials and Methods: 145 patients, who underwent total thyroidectomy for benign goiters and early carcinoma thyroid ( 3 had 91% sensitivity, 84% specificity with a PPV of 71% and NPV of 95%, whereas score of ≥ 4 had 100% specificity and PPV in predicting CSH. Conclusions: CSH after TT is multi-factorial, and a combination of factors (Hypocalcemia prediction score > 3) can be used to predict it so as to discharge patients within 24 hours after surgery.

Candidemia in intensive care unit patients: a one year study from a tertiary care center in South India.

Abstract: Background: The occurrence of candidemia is on a rise worldwide. Non-albicans Candida species have emerged as major causes of candidemia in many countries. Added to it is the problem of antifungal resistance in Candida isolates. Objectives: To find out the prevalence of candidemia in our intensive care unit (ICU) setup along with the antifungal susceptibility pattern of Candida isolates and various risk factors associated with candidemia. Materials and Methods: All Candida isolates from blood stream infections of ICU patients were included in the 1 year study period (November 2008-October 2009). The isolates were speciated using various phenotypic tests. Antifungal susceptibility testing was done by disk diffusion methods according to Clinical and Laboratory Standards Institute guidelines and also using CANDIFAST. Various risk factors associated with the development of candidemia were looked into. Results: A total of 39 Candida isolates were isolated during the study period of 1 year (prevalence of 0.65%). Candida tropicalis (74.35%) was the most common isolate followed by Candida albicans, Candida parapsilosis, Candida krusei and Candida glabrata. All the 39 Candida isolates (100%) were sensitive to amphotericin B while 12 isolates (30.8%) were resistant to fluconazole. The risk factors commonly associated with candidemia patients were long term antibiotic therapy (64.1%), use of central venous catheters (56.4%), urinary catheters (53.9%), steroid therapy (35.9%) and diabetes mellitus (33.3%). Conclusion: Candidemia is emerging as a significant problem in hospitalized patients, especially in ICU setups. Non-albicans Candida species are the major cause of candidemia as found in our study and few other studies in India. Multicentric studies involving many hospitals are required to know the true prevalence of candidemia and the status of antifungal drug resistance among Candida isolates in our country.

Risk factors associated with death among influenza A (H1N1) patients, Tamil Nadu, India, 2010.

Abstract: Background: Limited information is available about the risk factors associated with death among patients of influenza A (H1N1) in India. Aims: To describe the epidemiology of laboratory-confirmed influenza A (H1N1) patients and identify risk factors associated with death. Settings and Design: We reviewed the surveillance data of laboratory-confirmed patients in Tamil Nadu, India, for the year 2010. We conducted a case-control study by comparing 70 laboratory-confirmed A (H1N1) patients who died (cases) with 210 A (H1N1) patients who recovered (controls) to identify the risk factors for deaths. Materials and Methods: We interviewed the controls and immediate care-takers of the influenza patients who died to collect information about socio-demographic details and co-morbid conditions. We used an abstraction form to collect the information about the clinical details from the case records of the hospitals where the cases and controls received treatment. Statistical Analysis: We analysed the surveillance data by time, place and person. We conducted univariate and multivariate logistic regression analysis for identifying factors associated death. Results: During 2010, 1302 laboratory-confirmed cases were reported to the Tamil Nadu surveillance unit. Of these, 72 patients died (case fatality=5.5%). About 2/3 of the cases and 40% of the deaths were from three districts. On multivariate analysis, past history of diabetes, treatment in private hospitals, treatment with corticosteroids during illness, visit to >1 healthcare facility before laboratory confirmation and delay of >48 h in starting antivirals were found to be independently associated with the deaths. Conclusions: Influenza patients with previous history of diabetes, who had treatment with corticosteroids during illness, and started with antivirals after 48 h of onset of symptoms, were at higher risk of adverse outcome. In order to reduce the risk of death during future waves of influenza in Tamil Nadu, the physicians need to be sensitised regarding (1) higher risk of adverse outcomes among A (H1N1) patients with diabetes; (2) adherence to the national protocol for categorisation of cases; (3) prompt initiation of antivirals for severe cases; and (4) avoidance of systemic corticosteroids during management.

Pure red cell aplasia following autoimmune hemolytic anemia: an enigma.

Abstract: A 26-year-old previously healthy female presented with a 6-month history of anemia. The laboratory findings revealed hemolytic anemia and direct antiglobulin test was positive. With a diagnosis of autoimmune hemolytic anemia (AIHA), prednisolone was started but was ineffective after 1 month of therapy. A bone marrow trephine biopsy revealed pure red cell aplasia (PRCA) showing severe erythroid hypoplasia. The case was considered PRCA following AIHA. This combination without clear underlying disease is rare. Human parvovirus B19 infection was not detected in the marrow aspirate during reticulocytopenia. The patient received azathioprine, and PRCA improved but significant hemolysis was once again documented with a high reticulocyte count. The short time interval between AIHA and PRCA phase suggested an increased possibility of the evolution of a single disease.

Vismodegib: the first drug approved for advanced and metastatic basal cell carcinoma.

Abstract: Treatment of basal cell carcinoma (BCC) usually involves surgical interventions and laser ablation, but in locally advanced BCC, which arise either from earlier untreated lesions or from recurrence of aggressive BCC, surgery and radiotherapy are not helpful. Vismodegib, the first oral-targeted therapy for locally advanced and metastatic BCC, unsuitable for surgery or radiotherapy, was recently approved by US Food and Drug Administration (FDA). The drug was under the priority review program of FDA and was approved on the basis of promising results of phase II trial. Vismodegib acts by targeting the hedgehog pathway, which is activated abnormally in most BCCs. Approval of vismodegib is a big step ahead in the treatment of advanced BCC, where there was no other effective drug therapy till now.

Marine stingray injuries to the extremities: Series of three cases with emphasis on imaging.

Abstract: Stingray injuries are usually reported from coastal regions. The injury is caused by the tail spine of the stingray, which can penetrate deep into the soft tissues, and the venom in the tail can cause extensive tissue damage. Imaging plays a very important role in patients with stingray injuries, especially to detect the presence of retained foreign bodies and its complications. We present three cases of stingray injuries to the extremities, with a special emphasis on radiographic findings. Embedded foreign bodies that were radiographically visualized were removed in two of the patients (one patient was discharged at request and was lost to follow-up). We also discuss the types of injuries, clinical presentation, importance of imaging and management considerations in stingray injuries.

Acute myocardial infarction: can it be a complication of acute organophosphorus compound poisoning?

Abstract: Organophosphorus compounds are used as pesticides and represent a common cause of poisoning in developing countries including India due to their widespread availability and use. Toxicity due to these agents can affect many organs including heart. Here, we report a case of acute organophosphorus poisoning (parathion), followed by acute myocardial infarction; documented by clinical features, electrocardiographic changes, and elevated cardiac enzymes. Myocardial infarction has been rarely reported with organophosphorus compounds exposure, thus awareness of this complication can reduce morbidity and mortality.

Transcription activity of MMP-2 and MMP-9 metalloproteinase genes and their tissue inhibitor (TIMP-2) in acute coronary syndrome patients.

Abstract: Background: Acute coronary syndromes (ACS) are a consequence of coronary vessel atherosclerosis and they are a leading cause of death in industrialized countries. One of the ACS causative factors is the deranged ratio equilibrium of the matrix metalloproteinase/tissue inhibitor of metalloproteinases (MMPs/TIMPs). Aims: Assessment of transcriptional activity of metalloproteinase genes using Human Genome-U133A oligonucleotide microarrays and selection of candidate genes differentiating ACS patients from healthy subjects and finally, QRT-PCR (quantitative real time polymerase chain reaction) confirmation of the results. Settings and Design: The study involved 67 ACS patients, admitted on a consecutive basis, to the Cardiology Clinic as well as 24 healthy subjects (control). Materials and Methods: Ribonucleic acid isolated from peripheral blood mononuclear cells was analyzed by QRT-PCR. Transcriptional activity of the analyzed gene was assessed with TaqMan gene expression assays. Statistical Analysis: U Mann-Whitney test was used to compare the results. Results: Homogeneity of the investigated group was assessed through hierarchical clusterization whereas the nine genes differentiating ACS patients from healthy persons were selected using the Bland-Altman technique. Among these genes three (platelet derived growth factor D, NUAK family SNF1-like kinase 1 and peroxisomal biogenesis factor 1) showed decreased transcriptional activity whereas the remaining six genes (MMP-2 and MMP-9, CDK5RAP3, transmembrane BAX inhibitor motif containing 1, adenylate cyclase-associated protein 1 and TIMP-2) were increased. MMP-2, MMP-9 and TIMP-2 were further characterized by QRT-PCR. Conclusions: The obtained results permit to conclude that the increased expression of MMP-2 and MMP-9 metalloproteinases and their tissue inhibitor (TIMP-2) is responsible for disturbed equilibrium of the metalloproteinase/tissue inhibitors system and as a consequence, for destabilization of atherosclerotic plaque and occurrence of the acute coronary syndrome in the investigated group of patients.

Clozapine re-challenge under the cover of Filgrastim.

Abstract: Rechallenge with clozapine, despite a history of clozapine-induced neutropenia is considered in patients with a good response to the drug in the past, for whom no other treatments are effective, and in cases where the risks of withholding treatment are greater than the risks of rechallenge. Dyscrasias that occur during rechallenge are reportedly earlier in onset and longer lasting. Strategies advocated during rechallenge include frequent monitoring of white blood counts, the use of lithium or Granulocyte-Colony Stimulating Factors. We report a case of a patient with treatment-resistant schizophrenia who developed neutropenia with clozapine as a result of which the drug was discontinued. However poor response to other first and second-generation antipsychotic medication and the persisting risk of harm to himself and others necessitated the reconsideration of clozapine. The patient was re-challenged with clozapine under the cover of Filgrastim, a Granulocyte-Colony Stimulating Factor.

An observational study of complications in chickenpox with special reference to unusual complications in an apex infectious disease hospital, Kolkata, India.

Abstract: Background: Chickenpox can cause serious complications and even death in persons without any risk factors. Aims: To observe the different complications with special reference to unusual complications of chickenpox and their outcomes. Materials and Methods: The present study was a prospective observational study where 300 patients suffering from chickenpox were evaluated with special reference to unusual complications and outcomes. Results: The usual complications of chickenpox commonly observed were acute hepatitis in 30 (10%) and cerebellar ataxia in 22 patients (7.3%), whereas common unusual complications were acute pancreatitis in 45 (15%), hemorrhagic rash in 10 (3.3%), Guillain-Barrι syndrome in 4 (1.3%), disseminated intravascular coagulation in 4 (1.3%), necrotizing fasciitis in 4 (1.3%), and acute renal failure in 3 patients (1%). It had been observed that most of these unusual complications occurred in patients without any risk factor. A total of 18 patients (6%) died in this study and of them 12 patients (4%) died due to unusual complications. Conclusions: Compulsory childhood varicella vaccination including vaccination of risk groups and susceptible individuals are all essential to reduce the incidence of chickenpox, associated complications, and subsequent death.

A comparison of the quality of the information available on the internet on interventional radiology, vascular surgery, and cardiology.

Abstract: Context and Aims: Internet use is rapidly expanding and increasingly plays a substantial role in patient education. We sought to evaluate and compare the quality of information available to patients online on three closely linked specialties: Interventional radiology (IR), cardiology, and vascular surgery. Materials and Methods: We searched the leading three search engines for the terms: Interventional Radiology, cardiology, and vascular surgery, collating the top 50 hits from each search. After excluding duplicates and irrelevant sites, 43, 25, and 36 sites remained, respectively. Sites were analyzed using the LIDA instrument (an online tool for assessing health-related websites) and Fleisch Reading Ease Scores (FRES) were compared across the different search terms and correlated with the country of origin and certification by the Health on the Net (HON) Foundation. Results: There was no significant difference ( P>0.05) in the total LIDA, accessibility, usability or reliability scores between the three specialties. HONCode certification was associated with higher LIDA (83.1±1.6 vs. 71.53±0.8 ( P<0.0001)), reliability (75.7±3.6 vs. 49.0±1.6 ( P<0.0001)) and FRES (37.4±4.0 vs. 29.7±1.4 ( P=0.0441)). Conclusion: Websites are generally well designed and easy to use; the majority however, lacks currency and reliability. Despite similarity in quality of online information, there is a disparity in knowledge of IR; this may be due to low web-traffic figures of IR sites. Wikipedia's user-generated content, ranks highly in major search engines, as such; this could serve as means of disseminating reliable health information to patients.

Does first line antiretroviral therapy increase the prevalence of cardiovascular risk factors in Indian patients?: A cross sectional study

Abstract: Context: Antiretroviral therapy (ART) is associated with a myriad of metabolic complications which are potential cardiovascular risk factors. Early detection of these risk factors could help in alleviating morbidity and mortality in human immunodeficiency virus (HIV) infected patients on ART. Aims: To study the prevalence of cardiovascular risk factors in patients on a combination of nucleoside reverse transcriptase inhibitors (NRTIs) and non-NRTIs (NNRTIs) - the standard combination first line ART regimen used in tertiary referral center. Settings and Design: The prevalence of cardiovascular risk factors in HIV infected subjects with stage 1t disease on standard first line ART for at least 1 year, HIV infected subjects with stage 1 disease and not on ART and HIV negative subjects was assessed. The study was a cross-sectional study design. Materials and Methods: Basic demographic data was collected and patients were examined for anthropometric data and blood was collected for analysis of blood glucose, serum lipids, and fasting insulin levels. Statistical Analysis: Chi-square test was used to calculate significance. Statistical Package for Social Sciences (SPSS) software version 16.0 was used for data analysis. Results: The prevalence of hypercholesterolemia and hypertriglyceridemia was higher in the patients on ART when compared to patients not on ART ( P Conclusions: First line ART is associated with increased prevalence of dyslipidemia. Early detection and treatment of dyslipidemia should help in reducing the cardiovascular morbidity in patients on ART.

Diffusion weighted MR imaging of 5-fluorouracil and oxaliplatin-induced leukoencephalopathy.

Abstract: A 55-year-old man treated with 5-fluorouracil and oxaliplatin for advanced sigmoid colon cancer presented with seizures, progressive gait and balance difficulties with frequent falls and slurring of speech. After three cycles of chemotherapy, brain magnetic resonance imaging using diffusion-weighted imaging clearly revealed the presence of high signal intensity in the deep white matter of the bilateral cerebral hemispheres, including the corpus callosum symmetrically. A diagnosis of acute leukoencephalopathy was made based on these findings. His clinical symptoms normalized after the discontinuation of the chemotherapy. Early detection of drug-induced leukoencephalopathy is important as the clinical symptoms can be reversed by early discontinuation of the causative drug. Diffusion-weighted magnetic resonance imaging is a useful modality for the early detection and definitive diagnosis of this characteristic encephalopathy.

Genetic instability in urinary bladder cancer: An evolving hallmark

Abstract: Bladder cancer is a major health-care concern. A successful treatment of bladder cancer depends on its early diagnosis at the initial stage. Genetic instability is an essential early step toward the development of bladder cancer. This instability is found more often at the chromosomal level than at the nucleotide level. Microsatellite and chromosomal instability markers can be used as a prognostic marker for screening bladder cancer. Bladder cancer can be distinguished in two different categories according to genetic instability: Cancers with chromosomal level instability and cancers with nucleotide level instability. Deoxyribonucleic acid (DNA) mismatch repair (MMR) system and its correlation with other biologic pathway, both are essential to understand the basic mechanisms of cancer development. Microsatellite instability occurs due to defects in DNA MMR genes, including human mutL homolog 1 and human mutL homolog 2. Chromosomal alterations including deletions on chromosome 3, 8, 9, 11, 13, 17 have been detected in bladder cancer. In the current review, the most recent literature of genetic instability in urinary bladder cancer has been summarized.

Telaprevir: changing the standard of care of chronic hepatitis C.

Abstract: Chronic hepatitis C is a major public health problem and its burden is expected to increase in the near future Out of six genotypes of hepatitis C virus (HCV) identified, genotype 1 is the most prevalent genotype in America and Europe With peg-interferon alpha and ribavirin dual therapy, sustained virological response (SVR) is achieved in less than half of the patients infected with HCV genotype 1 Moreover, this dual therapy also causes many intolerable adverse effects Telaprevir is an HCV protease inhibitor approved for chronic hepatitis C genotype 1 mono-infection It is a type of direct acting antiviral drug acting through inhibition of viral non-structural 3/4A protease It can be safely administered in mild hepatic dysfunction Due to inhibition of CYP3A4 and P-glycoprotein, significant drug-drug interactions are possible with telaprevir Trials have shown significantly higher SVR rates when telaprevir is added to peg-interferon alpha and ribavirin, particularly in patients with unfavorable prognostic factors It is approved for use in treatment-naive and previously treated patients Rash and anemia are the major troublesome side-effects Next-generation protease inhibitors may overcome the drawbacks of telaprevir and another approved HCV protease inhibitor - boceprevir Evidence from small scale studies suggests that telaprevir may be used in conditions like HIV co-infection, post-transplantation and some HCV non-1 genotype infections also Preliminary data show higher SVR rates with triple therapy even in patients with unfavorable interleukin-28B (IL28B) genotype With development of other direct acting antivirals, it might be possible to treat chronic hepatitis C with interferon-free regimens in future This article briefly reviews the properties of telaprevir and its status in the context of rapidly evolving aspects of management of chronic hepatitis C