A randomized placebo-controlled double-blind study of levamisole in the treatment of limited and slowly spreading vitiligo

BACKGROUND

A previous uncontrolled, open trial of levamisole in patients with limited and slowly spreading vitiligo had shown that new lesions did not develop in 94% of patients after 2-4 months of treatment with the drug.

OBJECTIVES

To assess the efficacy of levamisole in the treatment of slowly spreading, limited vitiligo.

METHODS

In a randomized double-blind trial at the Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India, 60 patients with vitiligo involving < 2% of the body surface area and with slowly spreading disease (defined as one to five new lesions in the previous month or six to 15 new lesions in the previous 3 months) were randomly allocated to receive oral levamisole 150 mg or placebo on two consecutive days in a week. Children received oral levamisole 100 mg. All patients applied mometasone furoate 0.1% cream on the depigmented macules once daily. Patients were evaluated monthly for 6 months. The main outcome measure was the occurrence of new lesions, counted at each monthly visit. The secondary outcome measures comprised: (i) a dermatology-specific instrument, the Dermatology Life Quality Index or Children's Dermatology Life Quality Index questionnaires, which were completed by the patients at baseline and at every visit, and (ii) a general health questionnaire, the World Health Organization Quality of Life Brief Questionnaire, which was completed at baseline and at the end of the study.

RESULTS

Forty-three patients completed 6 months of follow-up. The mean +/- SD number of new lesions that developed during the study period of 6 months was 1.9 +/- 2.0 (range 0-8) in the levamisole group and 1.8 +/- 2.0 (range 0-7) in the placebo group (P = 0.92). The proportion of patients who did not develop any further new lesions for the remainder of the study period was higher in the levamisole group at all the monthly evaluation points, although it was statistically significant (P = 0.05) only at the fourth month. Improvement in quality of life was similar in both groups.

CONCLUSIONS

The study indicates that levamisole is not as effective in arresting disease progression as was observed in a previous open study. A study with a larger sample size is necessary to determine if levamisole is truly superior to placebo in this respect.

Need for dedicated focus on urban health within National Rural Health Mission

National Rural Health Mission represents an important public health initiative to address essential health needs of the country's underserved population. For the Mission to achieve its goals, urban population needs to be included in its scope. Urban poor population constitutes nearly a third of India's urban population and is growing at three times the national population growth rate. Health status and access of reproductive and child health services of slum dwellers are poor and comparable to the rural population. Efforts to improve the conditions of urban poor necessitate strengthening national policy and fiscal mandate, augmenting and strengthening the urban health delivery system, coordinating among multiple stakeholders, involving private sector, strengthening municipal functioning and building community capacities. National Rural Health Mission should be broadened to National Public Health Mission. This paper discusses issues pertaining to health conditions of the urban poor, present status of services, challenges and suggests options for NRHM to bridge the large gap.

Collateral artery aneurysm: a unique presentation of thoracic outlet syndrome

Aneurysms of collateral arteries are unusual. A case of transverse cervical artery aneurysm as the sole presentation of vascular thoracic outlet syndrome is presented and the relevant literature reviewed.

Hemoglobin E-beta thalassemia: factors affecting phenotype

The phenotype of E-beta-thalassemia is affected by several genetic factors. The aim of this study was to analyze severity of E-beta-thalassemia and correlate with HbE, HbF, E/F ratios, beta-mutation and Xmn I polymorphism. Thirty cases of E-beta-thalassemia (23 with childhood onset) were studied. HbE levels were quantitated by HPLC. Xmn1 polymorphism and beta-mutations were studied by PCR-RFLP and ARMS respectively. Commonest features were pallor (100%), splenomegaly (74%), and hepatomegaly (65%), 43% (10/23) were on regular transfusions at diagnosis. One case presented with paraplegia. Patients heterozygous for Xmn I polymorphism (+/-) had later onset (>3 yrs) compared to homozygous (-/-) absence (0.5-2.8 yrs). Most (69.6%) showed beta-mutation IVS 1-5 (G-->C). Negative correlation was found between age of onset and HbE. Thus, presentation is similar to previously reported Thai cases. Heterozygosity of Xmn I polymorphism also delays disease onset. Early diagnosis facilitates appropriate management and prenatal diagnosis.

Knee dislocation with ipsilateral femoral shaft fracture: a report of five cases

We report the management and outcome of 4 patients with 5 knee dislocations associated with ipsilateral femoral shaft fractures. All patients were managed by immediate reduction of the knee dislocation, intramedullary nailing of the femur, and angiography, followed by postoperative immobilization of the knee (brace or external fixation) for a minimum of 6 weeks. Four of the 5 dislocations underwent a secondary ligament reconstruction. At the 2-year follow up, the mean Knee Society Score was 133 (range 99-170).

Invasive aspergillosis involving multiple paranasal sinuses - A case report

A case of invasive multiple paranasal sinus aspergillosis with bony involvement is reported. A young immunocompetent lady presented with bilateral nasal obstruction due to polyps. Radiologically and histopathologically a fungal cause was kept a possibility, and the diagnosis of Aspegillus fumigatus was established by demonstration of acute angle branching septate hyphae on direct wet mount and repeated isolation in culture. Patient responded favourably to surgical excision of polyps and oral itraconazole post operatively.

Dark ground microscopy and treponemal serological tests in the diagnosis of early syphilis

OBJECTIVES

To evaluate the use of dark ground microscopy (DGM) and treponemal serological tests in the diagnosis of primary (PS) and secondary (SS) syphilis.

METHODS

A retrospective case note review of patients with early syphilis who attended our department between January 2001 and December 2002. Data were collected on demographics, results of treponemal serology and DGM.

RESULTS

50 individuals had PS and 36 individuals had SS. DGM was performed in 31/50 (62%) of PS cases and this was positive in 97%. In 17 (34%) cases of PS, treponemal EIA was negative initially. DGM was performed on 13 of these, all of which were positive. Therefore, EIA had a sensitivity of 57% when compared to DGM. In 27 patients where EIA-IgM was performed, this was positive in 22 (81%), of which 12 were EIA negative on initial screening. All SS cases had positive EIA. DGM was performed in 19/36 (52%) of SS cases and was positive in 16/19--that is, a sensitivity of 84% when compared to EIA. The major reason why DGM was not performed in the cases of PS was that herpes was the presumed diagnosis and in SS the rash was attributed to other causes.

CONCLUSIONS

DGM is a rapid and sensitive test while EIA takes time for results and is less sensitive in PS. EIA-IgM is a useful adjunct in PS. DGM allows immediate diagnosis, treatment, and partner notification preventing further transmission. Genitourinary medicine clinics should have trained staff to perform DGM on all anogenital ulcers and suspected syphilitic lesions.

Effects of metformin treatment on luteal phase progesterone concentration in polycystic ovary syndrome

The causes of luteal phase progesterone deficiency in polycystic ovary syndrome (PCOS) are not known. To determine the possible involvement of hyperinsulinemia in luteal phase progesterone deficiency in women with PCOS, we examined the relationship between progesterone, luteinizing hormone (LH) and insulin during the luteal phase and studied the effect of metformin on luteal progesterone levels in PCOS. Patients with PCOS (19 women aged 18-35 years) were treated with metformin (500 mg three times daily) for 4 weeks prior to the test cycle and throughout the study period, and submitted to ovulation induction with clomiphene citrate. Blood samples were collected from control (N = 5, same age range as PCOS women) and PCOS women during the late follicular (one sample) and luteal (3 samples) phases and LH, insulin and progesterone concentrations were determined. Results were analyzed by one-way analysis of variance (ANOVA), Duncan's test and Karl Pearson's coefficient of correlation (r). The endocrine study showed low progesterone level (4.9 ng/ml) during luteal phase in the PCOS women as compared with control (21.6 ng/ml). A significant negative correlation was observed between insulin and progesterone (r = -0.60; P < 0.01) and between progesterone and LH (r = -0.56; P < 0.05) concentrations, and a positive correlation (r = 0.83; P < 0.001) was observed between LH and insulin. The study further demonstrated a significant enhancement in luteal progesterone concentration (16.97 ng/ml) in PCOS women treated with metformin. The results suggest that hyperinsulinemia/insulin resistance may be responsible for low progesterone levels during the luteal phase in PCOS. The luteal progesterone level may be enhanced in PCOS by decreasing insulin secretion with metformin.

Does I-131-MIBG underestimate skeletal disease burden in neuroblastoma?

BACKGROUND

Controversy persists as to the need for both MIBG and bone scanning in routine evaluation of neuroblastoma.

AIM

To compare the efficacy of I-131- metaiodobenzylguanidine (MIBG) scan against that of conventional Tc99m- methylene diphosphonate (MDP) bone scan for the detection of skeletal deposition of neuroblastoma.

METHODS AND MATERIAL

The study included 57 patients (36 boys, 21 girls: age range 1-14 years) of neuroblastoma who underwent both bone scan with Tc99m-MDP and I-131-MIBG scan within 15 days of each other at presentation and during follow-up.

RESULTS

At presentation 11(19.2%) patients had evidence of skeletal metastases on MDP scan against 7 patients who showed bony secondaries on MIBG scan. Of the 7 patients, with positive MIBG and MDP scans, MDP scan detected 11 sites whereas MIBG scan detected 7 sites. On follow-up study, 3 patients with initial abnormal MDP scan but normal MIBG scan, developed skeletal metastases detectable on MIBG scan, whereas 3 of the 46 patients who had normal MDP and MIBG scan at presentation; developed skeletal metastases detectable on MDP scan. MIBG scan was concordant in 2 of them but was normal in the third patient.

CONCLUSION

I-131-MIBG underestimates skeletal disease burden in neuroblastoma. Therefore, Tc99m-MDP bone scan should remain a part of routine assessment of patients with neuroblastoma.

The problem of appraising qualitative research

Qualitative research can make a valuable contribution to the study of quality and safety in health care. Sound ways of appraising qualitative research are needed, but currently there are many different proposals with few signs of an emerging consensus. One problem has been the tendency to treat qualitative research as a unified field. We distinguish universal features of quality from those specific to methodology and offer a set of minimally prescriptive prompts to assist with the assessment of generic features of qualitative research. In using these, account will need to be taken of the particular method of data collection and methodological approach being used. There may be a need for appraisal criteria suited to the different methods of qualitative data collection and to different methodological approaches. These more specific criteria would help to distinguish fatal flaws from more minor errors in the design, conduct, and reporting of qualitative research. There will be difficulties in doing this because some aspects of qualitative research, particularly those relating to quality of insight and interpretation, will remain difficult to appraise and will rely largely on subjective judgement.

The problem of appraising qualitative research

Qualitative research can make a valuable contribution to the study of quality and safety in health care. Sound ways of appraising qualitative research are needed, but currently there are many different proposals with few signs of an emerging consensus. One problem has been the tendency to treat qualitative research as a unified field. We distinguish universal features of quality from those specific to methodology and offer a set of minimally prescriptive prompts to assist with the assessment of generic features of qualitative research. In using these, account will need to be taken of the particular method of data collection and methodological approach being used. There may be a need for appraisal criteria suited to the different methods of qualitative data collection and to different methodological approaches. These more specific criteria would help to distinguish fatal flaws from more minor errors in the design, conduct, and reporting of qualitative research. There will be difficulties in doing this because some aspects of qualitative research, particularly those relating to quality of insight and interpretation, will remain difficult to appraise and will rely largely on subjective judgement.

Laparoscopic Surgical Management of Perforative Peritonitis in Enteric Fever

Early surgery in enteric perforation is the only accepted form of treatment in modem day medicine and gives excellent results. Exploratory laparotomy continues to be the mainstay of surgical treatment and several different procedures are recommended in literature. Between January 1998 and November 2001, we have successfully managed 6 consecutive cases of enteric perforation laparoscopically with complete resolution of the disease. There were 4 males and 2 females in our study. The mean time of presentation to us was 38 hours after the perforation (range 22 hours to 63 hours). The mean age was 32 years (range 28 years to 43 years). All patients presented with free air under the diaphragm. A laparoscopic approach was carried out through a 10 mm supraumbilical port and two 5 mm additional ports in the midline infraumbilical area and the left iliac fossa area. Simple one layer closure of the perforation was carried out with 2-0 silk intracorporeally and the peritoneal cavity was washed out and adequately drained. All perforations were localised to the terminal ileum and were single in number. The mean operating time was 54 minutes-(range 42 to 75 minutes). All patients received parenteral ofloxacin and metrogyl. Postoperative recovery was uneventful in all patients and there were no major complications. All patients were discharged from hospital by the 4th postoperative day. Follow up over a period of 12 to 16 months revealed all patients to be in normal health. We strongly recommend a first line laparoscopic approach in all patients with typhoid perforation; as it is a safe and effective method of managing such cases.

High strain rate testing of kidney stones

Sections of struvite kidney stones were tested in compression at high strain rates ( approximately 3000s(-1)) using a Kolsky bar and at low strain rates ( < 0.001 s(-1)) using an Instron testing machine. The peak stress in both cases appeared to be similar. At high strain rates the values of flow stress measured were between 40 and 65 MPa and at low strain rates they were between 37 and 58 MPa. However, the morphology of the damage was dramatically different. Stones tested at low strain rates formed a small number of cracks but otherwise remained intact at the end of the test. In comparison, stones tested at high strain rates were reduced to a powder. Kidney stones are a two-phase material consisting of a crystalline ceramic phase and an organic binder. We speculate that in the high strain rate tests the large difference in the sound speed between the matrix and the crystalline grains leads to shear stresses that destroy the stone. These data indicate that shear stress induced by the internal structure may be a mechanism by which shock waves comminute kidney stones in lithotripsy.