CYP2C9*3 polymorphism presenting as lethal subdural hematoma with low-dose warfarin

Warfarin is the most common and cheap oral anticoagulant currently used in clinical practice. A high inter-individual variation is seen in the response to warfarin. Recently, pharmacogenetics has gained importance in managing patients on warfarin, both in predicting the optimum required dose as well as in decreasing the risk of bleeding. This case report is a description of a 49-year-old patient who had a lethal subdural hematoma with low-dose warfarin. He was subsequently found to have CYP2C9 gene polymorphism (*1/*3). This case report stresses the importance of pre-prescription assessment of genetic analysis for those initiated on warfarin.

Controversies and dilemmas in allogeneic transplantation for myelofibrosis

JAK1/2 inhibitors have broadened the therapeutic options in myelofibrosis. Though not curative, they result in a meaningful clinical benefit with relatively fewer side effects. In contrast, allogeneic hematopoietic cell transplantation (HCT) is a potentially curative option, but is associated with significant morbidity and mortality. Hence, an important question is the optimal timing of HCT in the era of JAK inhibitors. Timing of HCT is a crucial decision, and need to be individualized based on the personal preferences and goals of therapy; in addition to patient, disease, and transplant related factors. Risk stratification by the currently established prognostic scoring systems need to be further refined by incorporation of prognostically significant mutations to guide the treatment choices better. Data on use of JAK inhibitors prior to HCT have just started to emerge. We discuss some of the current controversies and dilemmas in transplantation for myelofibrosis based on a few real life scenarios.

Cross-sectional evaluation of awareness of prevention of dental caries among general pediatricians in ghaziabad district, India

BACKGROUND

Oral diseases are largely preventable and it is hoped that with the early exposure to oral health-care activities, the prevalence of oral diseases will be reduced in children and they would be more receptive to dental services.

AIM

The present study evaluated the awareness of prevention of dental caries among pediatricians in Ghaziabad district, India.

SUBJECTS AND METHODS

A cross-sectional survey was undertaken among the pediatricians in Ghaziabad district, India. Total subjects including in the survey were 88 pediatricians, through systemic random sampling. Both the gender was including Male-37.8% (35/88) and Female-62.2% (53/88). Pre-tested, structured and self administered questionnaire was used in the survey and data analysis was done by using 'SPSS' software version 16.0 (IBM, United States).

RESULTS

Our study indicated that most of the pediatricians in Ghaziabad district had moderate knowledge 39.7% (35/88), followed by good knowledge 36.5% (32/88) and poor knowledge 23.8% (21/88) about dental caries. Practice guidelines and opinions of pediatricians in the survey were moderate 64.7% (57/88) in about more than half, followed by poor 23.8% (21/88) and followed by good 11.5% (10/88). The attitude for prevention of dental caries was positive in almost everybody 81.8% (72/88).

CONCLUSION

The present survey concluded that pediatricians in Ghaziabad district, India had a good attitude and practices, but had moderate knowledge and lacked proper awareness about dental caries.

Janus kinase inhibitors and allogeneic stem cell transplantation for myelofibrosis

Myelofibrosis (MF) is a manifestation of several disorders of hematopoiesis, collectively referred to as myeloproliferative neoplasms. Allogeneic hematopoietic stem cell transplantation (ASCT) is the only therapy with proven curative potential. However, most patients with MF are in their 6th or 7th decade of life, and only some of these patients have been considered suitable transplantation candidates. The development of reduced-intensity conditioning regimens with limited toxicity has allowed clinicians to offer ASCT to a growing number of older patients. The availability of Janus Kinase (JAK) 1/2 inhibitors allows clinicians to provide symptom relief and improved quality of life for MF patients. These drugs may also affect the decision regarding, in particular, the timing of ASCT. Future studies need to address the role of JAK1/2 inhibitors in patients who are transplantation candidates and determine their role before and, possibly, after transplantation. The identification of indications for the use of JAK1/2 inhibitors in the context of transplantation may lead to new therapeutic strategies for patients with MF.

Isolated lichen planus of lower lip: a case report

Lichen planus is an idiopathic inflammatory condition, which may involve mucosa of the oral cavity, gastrointestinal tract, larynx or the cutaneous surface either in isolation or in combinations. Mucosal lichen planus is more common than the cutaneous variant. Isolated lip involvement is very rare and should be differentiated from other similar leukoplakic lesions. We are reporting a rare case of oral lichen planus in an elderly male that was exclusively localised to the lower lip.

Evaluation of Integrated Management of Neonatal and Childhood Illness (IMNCI) algorithm for diagnosis and referral in under-five children

A prospective observational study was conducted on 500 children to evaluate the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) algorithm for diagnosis and referral of children aged 0-59 mo. IMNCI algorithm performed well in diagnosis [except sepsis in 0-7 d (p < 0.01) and malaria in 2-59 mo (p < 0.01)] and referral of under five illnesses. The proportion of children with the mismatch between 'IMNCI' diagnosis and 'Gold Standard' diagnosis were highest (38.7 %) among children 0-7 d of age. The authors conclude that IMNCI algorithm in young children has good sensitivity for referring children with severe illnesses and is a good tool for diagnosis of most of childhood illnesses in under-five children.

Cutaneous Mycobacterium fortuitum Infection: Successfully Treated with Amikacin and Ofloxacin Combination

Cutaneous infections caused by atypical mycobacteria are uncommon and the diagnosis can be missed unless there is strong clinical suspicion supported by laboratory confirmation. We report a case of chronic discharging sinus caused by Mycobacterium fortuitum in a young healthy immunocompetent individual. The patient recovered completely following amikacin and ofloxacin therapy.

Assessment of red blood cell parameters and peripheral smear at different temperatures in case of cold agglutination disease

Cold agglutination disease (CAD) is characterized by an auto-antibody which is able to agglutinate red blood cells (RBCs) at temperatures lower than that of the body, and subsequently to activate the complement system responsible for lysis of RBCs. Patients show hemolytic anemia of varying degrees of severity, which arise or worsen upon exposure to low temperatures. We describe a case who presented with fever and symptoms of asthenia. His investigations yielded bizarre RBC parameters which led to suspicion of a rare CAD, which was confirmed on reviewing RBC parameters, peripheral smear and direct Coomb's test at different temperatures. Hence, we suggest assessment of bizarre RBC parameters and peripheral smear can help in laboratory testing and diagnosis of CAD. It should also not pose embarrassment in laboratory testing to the pathologist for making an early and accurate diagnosis, thus emphasizing the need for an early treatment of CAD.

Comparison of foetomaternal circulation in normal pregnancies and pregnancy induced hypertension using color Doppler studies

The aim of present study was to assess fetomaternal blood flows in normal and abnormal pregnancies using color Doppler indices. Subjects were divided into two groups as: Group A of 25 subjects of normal pregnancy as controls and group B of 25 subjects of pregnancy induced hypertension. All the subjects were lying in the age-group of 25-35 years and having 28 to 34 weeks of gestation; the patients were evaluated by detailed history and were subjected to complete general examination. Blood pressure was taken on two occasions at least 6 hours apart. Systemic examination and obstetrical examination was done in all subjects. All cases were subjected to pathological tests- Haemogram, Test for proteins in urine. Ultrasound assessment of fetal growth was done by measuring BPD (Biparietal diameter), HC (Head circumference), FL (Femur length) and AC (Abdominal circumference): Average gestational age and effective fetal weight was then calculated by ultrasound machine. Color Doppler was used to assess the various Doppler indices indices: Pulsatility index (PI), Resistive index (RI) and Systolic diastolic ratio (S/D ratio) in bilateral uterine, umbilical and middle cerebral arteries and compared to the standard normograms. Percentage of subjects having abnormal Doppler indices were calculated. Assessment of percentage of SGA (small for gestational age) fetuses was done in all the three groups. Decline in mean values of all Doppler indices was found with advancing gestational age in normal pregnancy suggesting decreased vascular resistance and increased blood flow in fetomaternal circulation. In pregnancy induced hypertensives, the mean values of Doppler indices showed a decline as in normal pregnancy but showed an increase (more than 2 S.D. of the mean) for that gestational age in comparison to the control group suggesting increased impedance to blood flow in uteroplacental and fetomaternal circulation. Umbilical artery Doppler indices were found to be the most sensitive indicator of uteroplacental and fetoplacental insufficiency in pregnancy induced hypertensives (P = 0.001). Thus we concluded that color Doppler can detect changes in fetomaternal circulation which correlate strongly with the fetal growth and therefore associated with pregnancy outcome.

Wedgeless 'V' shaped distal femoral osteotomy with internal fixation for genu valgum in adolescents and young adults

The treatment of angular malalignment includes restoration of normal mechanical axis alignment and joint orientation.The supracondylar wedgeless distal femoral 'V' osteotomy, as a treatment modality, is sparsely explored in the literature. This study was conducted at a tertiary level teaching referral hospital from October 2010 to September 2012. Forty six lower limbs (in 30 patients) were operated with a wedgeless 'V' osteotomy that was fixed with a buttress 'L' plate. The pre-operative deformity, post-operative correction and knee range of movement were noted. Mobilisation was started at 3 weeks after surgery and full weight-bearing was allowed at 3 months. The knee score by Bostman et al. was used for functional outcome. The mean age of the patients in our study was 16.9 years (range: 15 years to 23 years). The patients were followed up for a mean period of 19.8 months (range, 15 months to 29 months). The mean radiological tibiofemoral angle was 22.2 degrees (range, 16 degrees to 29 degrees) before surgery, that improved to a mean postoperative value of 5.1 degrees (range, 0 degrees to 10 degrees) (p < 0.001). The mean preoperative lateral distal femoral angle was 79.23 degrees that improved to a mean value of 89.13 degrees after surgery (p < 0.001). The mean mechanical axis deviation was 19.56 mm before surgery that improved to a mean postoperative value of 3.7 mm (p < 0.001). All patients reached a correction of the deformity and 44 cases out of a total of 46 had an excellent functional outcome, 2 patients had a good functional outcome. None had an unsatisfactory outcome. Two cases had a deep wound infection that subsided after implant removal. None of the cases had other complications. The distal femoral 'V' shaped osteotomy is a simple procedure for the correction of genu valgum in individuals nearing skeletal maturity and is easy to perform. It has the advantage of being wedgeless as it does not cause limb length discrepancy. Internal fixation helps in early rehabilitation after surgery.

Spider genomes provide insight into composition and evolution of venom and silk

Spiders are ecologically important predators with complex venom and extraordinarily tough silk that enables capture of large prey. Here we present the assembled genome of the social velvet spider and a draft assembly of the tarantula genome that represent two major taxonomic groups of spiders. The spider genomes are large with short exons and long introns, reminiscent of mammalian genomes. Phylogenetic analyses place spiders and ticks as sister groups supporting polyphyly of the Acari. Complex sets of venom and silk genes/proteins are identified. We find that venom genes evolved by sequential duplication, and that the toxic effect of venom is most likely activated by proteases present in the venom. The set of silk genes reveals a highly dynamic gene evolution, new types of silk genes and proteins, and a novel use of aciniform silk. These insights create new opportunities for pharmacological applications of venom and biomaterial applications of silk.

Spiders use self-produced venom and silk for their daily survival. Here, the authors report the assembled genome of the social velvet spider and a draft assembly of the tarantula genome and, together with proteomic data, provide insights into the evolution of genes that affect venom and silk production.

Sudden bilateral reversible vision loss: a rare presentation of acute intermittent porphyria

Acute intermittent porphyria is a rare disorder, characterised clinically by variable patterns of neurological and metabolic disturbances. We report a rare presentation with sudden onset painless bilateral reversible vision loss of cerebral origin along with a brief review of the underlying pathophysiology.