Weight loss for reduction of proteinuria in diabetic nephropathy: Comparison with angiotensin-converting enzyme inhibitor therapy

Reduction of weight in obese type 2 diabetes mellitus (T2DM) individuals is emerging as a significant strategy in the reduction of proteinuria in diabetic nephropathy along with control of hyperglycemia, hypertension, and dyslipidemia. The objective was to evaluate the reduction in 24-h proteinuria in T2DM patients with nephropathy by weight loss, with conventional therapy (angiotensin-converting enzyme [ACE] inhibitors) as the control arm. A prospective, randomized controlled trial was conducted between June 2010 and May 2011. T2DM patients with confirmed nephropathy by 24-h urinary protein estimation with a body mass index (BMI) of >25 kg/m² were studied. Patients who had nondiabetic nephropathy, uncontrolled hypertension (>125/75 mmHg) irrespective of antihypertensive drugs, excess weight due to edema or obesity due to other specific diseases, alcoholics, smokers, and patients who were on hemodialysis were excluded from the study. The patients were divided into three groups, namely, group A, patients on ACE inhibitor therapy; group B, patients on lifestyle modifications for weight loss; and group C, patients on an antiobesity drug (orlistat) and lifestyle modifications. At the end of 6 months, all the three groups were compared. Data were analyzed using software SPSS version 15.0. This study encompassed a total of 88 patients; 12 patients were dropped during the study period and 76 (group A: 22, group B: 23, and group C: 31) patients remained. The mean age of the patients was 58.36 ± 10.87 years (range: 30-70 years). At baseline, age, gender, mean BMI, waist-to-hip ratio (WHR), and 24-h proteinuria did not vary significantly among the three groups. At 6 months, the mean BMI significantly decreased in group C (P < 0.001) compared to that in the other two groups. Among the parameters BMI and WHR, the proportional form of BMI correlated well with the degree of reduction in proteinuria (r = 0.397, P = 0.01). Reduction in weight using lifestyle modifications and antiobesity drugs might improve renal function and proteinuria safely as observed in obese patients with diabetic nephropathy.

Ruptured seminoma of undescended testis presenting as acute abdomen: case report with literature review

We present a case of a 28-year-old male who presented with acute abdomen and was later diagnosed to be having ruptured intra-abdominal seminoma with hemoperitoneum, where the pre-operative diagnosis was not made. Laprotomy and complete excision were carried out. Rupture of intra-abdominal testicular seminoma is a rare cause of acute abdomen and hemoperitoneum. The pre-operative diagnosis is often difficult because history of cryptorchidism is not provided and imaging findings may be non-specific. In a male patient with acute abdomen and without previous history of orchidectomy, a testicular aetiology of acute abdomen should be kept as the differential diagnosis.

Health in Nepalese media

BACKGROUND

Coverage of health in Nepali print media is quite a recent phenomenon despite readers' ample appetite for it. Dominated by politics, Nepal's print media has been marginally publishing news pieces, features, editorials and op-ed articles, photographs and cartoons on health, though marginally. But the media did not wake up to the issues of human resources for health until lately.

METHODS

We content analysed the coverage of health issues including, human resources for health in select Nepali print media Kantipur, Nagarik and Annapurna Post of select three months in 2012 April, August and December. News pieces and their placements, Op-eds, editorials, features, letters to the editor, photos and cartoons were subjected to analysis.

RESULTS

Over the study period, the papers covered 544 health news pieces, 44% of political news pieces. Health workforce news pieces contributed 24% to it. However, only 10% of the health news made to the front pages. Coverage of health in editorials, features, Op-eds, photographs, cartoons and letters to the editor is even more meager. For example, only 7% of the editorials are relating to health.

CONCLUSIONS

Health is prioritized far less by the print media than politics despite the reader's appetite for it. Print media should give health a top priority, particularly in those areas that relate to health systems like human resources for health, for their massive impact on the lives of the people.

Antidiabetic and Antioxidant Activity of Scoparia dulcis Linn

The hypoglycaemic activity of methanol extract of Scoparia dulcis was performed on both in vitro and in vivo models along with determination of total extractable polyphenol. Methanol extract of Scoparia dulcis contains 4.9% and water extract contains 3.2% of total extractable polyphenol. The antioxidant activity showed very promising result in both the tested methods that is 2,2-diphenyl-1-picrylhydrazyl and ferric ion reducing capacity. The antioxidant activity is directly correlated to the antidiabetic potential of drug. The two enzymes (amylase and glycosidase) found in intestine are responsible for the increasing postprandial glucose in body. In vitro model was performed on these enzymes and the results showed that methanol extract of Scoparia dulcis was effective to check the postprandial glucose level. The in vivo hypoglycaemic activity of methanol extract of Scoparia dulcis was performed on streptozotocin-induced diabetes mellitus showed significant inhibition of blood glucose level as compared to control and similar to that of standard glibenclamide. The overall data potentiates the traditional value of Scoparia dulcis as an antidiabetic drug.

Antifungal and antioxidative potential of oil and extracts derived from leaves of Indian spice plant Cinnamomum tamala

Plant—based antimicrobials and antioxidants represent a vast untapped source for medicines and food supplements and hence have enormous therapeutic potential. Present work reports the fungicidal potential of Cinnamomum tamala Nees & Eberm (Lauraceae) leaf oil against five food spoilage and pathogenic fungi. In addition antioxidant efficacy of seven different solvent extracts derived from leaf was also evaluated using in vitro models. The oil demonstrated potent antifungal activity against Aspergillus niger, A. fumigatus, Candida albicans, Rhizopus stolonifer and Penicillium spp. in agar diffusion assay. Zone of inhibition ranged from 17-25 mm. The MFC values of oil against all the test fungi were found to be 230μg/ml. Phytochemicals present in C. tamala leaf were extracted in several solvents for assessing their effect in oxidative defense. The extracts exhibited appreciable antioxidant activity in β-carotene bleaching assay and reducing power assay. The antioxidative activities of extracts were compared with the activities of standard antioxidant compounds BHA and ascorbic acid. Petroleum ether, ethanol, acetone and chloroform extracts exhibited about 30-67% antioxidant activity in β-carotene bleaching assay. Aqueous and ethanol extracts exhibited better reducing power which increased gradually with increasing amount of the extract concentration showing dose dependent response. Results indicated that natural phytochemicals present in C. tamala leaf extracts have potential to prevent growth of food spoilage/pathogenic fungi. In addition they also have capability to mitigate the oxidative stress by antioxidant response.

Assessment of In vitro Sun Protection Factor of Calendula Officinalis L. (Asteraceae) Essential Oil Formulation

The present study was undertaken to study the sunscreen activity of herbal formulation. There is no evidence of the sun protection factor (SPF) studies on essential oil of Calendula flowers (Calendula officinalis L., Asteraceae). The study investigates the in vitro SPF by ultraviolet specrtophotometry method of Calendula flower oil in a cream formulation. Calendula oil was isolated by Clavenger's apparatus, compositions were identified by GC–MS and the cream of calendula flower oil was prepared by homogenization method followed by evaluation for physical parameters. The sun protection factor of cream was evaluated by in vitro method employing UV–visible spectrophotometer (Shimazdu-1600). The SPF of Calendula oil in cream formulation exhibited good activity (SPF = 14.84 ± 0.16). Finding of this study suggested that calendula oil cream can be used to protect the skin from UV radiations in form of sunscreen cream and to maintain the natural pigmentation of the skin.

Factors predicting surgical outcome of thymectomy in myasthenia gravis: A 16-year experience

Aim:

To assess the surgical outcome of myasthenia gravis (MG) following thymectomy and to determine the outcome predictors to such therapeutic approach.

Materials and Methods:

This study is a retrospective review of 80 consecutive thymectomies performed for MG over a 16-year period.

Results:

There were 41 females and 39 males (mean age, 34.32 years) with mean disease duration of 17.45 months prior to surgery. Stagewise distribution of the patients revealed 2.5% in stage I, 48.7% in stage IIA, 33.8% in stage IIB, 8.7% in stage III, and 6.3% in stage IV. The surgical approach was either trans-sternal (n=67) or video-assisted thoracoscopic route (n=13). Follow-up was obtained in 91.2% (n=73) of patients with mean duration of 67.7 months. At their last follow-up, 26.0% were in complete remission, 35.6% were asymptomatic on decreased medications, and 17.8% had clinical improvement on decreased medications. Overall, 79.4% of patients benefited from surgery, 8.2% had unchanged disease status, and 12.3% worsened clinically. Factors influencing favorable outcome include sex, disease stage, gland weight, and preoperative medication with anti-cholinesterase (P<0.05). There was one death in the perioperative period due to septicemia. Two patients died at fourth and seventh month following thymectomy.

Conclusion:

Thymectomy for MG is safe and effective. Certain influencing factors may shape treatment decisions and target higher risk patients.

Pistia stratiotes (Jalkumbhi)

Pistia stratiotes (Family: Araceae) is commonly used in Ayurvedic medicine. This review article is a compilation of all the updated information on its phytochemical and pharmacological activities, which were performed by different methods. Studies indicate that P. stratiotes possesses diuretic, antidiabetic, antidermatophytic, antifungal, and antimicrobial properties. These results are very encouraging and indicate that this plant should be studied more extensively to confirm the reproducibility of these results and also to reveal other potential therapeutic effects, along with some “leads” with possible isolation of active biomoieties and their mechanism of action.

Non-alcoholic fatty liver disease (NAFLD) is associated with low level of physical activity: a population-based study

BACKGROUND

High intensity exercise improves metabolic status and may potentially mobilise hepatic fat.

AIM

To assess the level of physical activity (PA) of subjects with non-alcoholic fatty liver disease (NAFLD).

METHODS

Data were obtained from NHANES (2003-2006). Activity counts obtained from accelerometer readings (ActiGraph, Fort Walton Beach, FL), from 7 consecutive days quantified total PA and time spent engaged in different levels of activity. All measures were counts/minutes/day: (sedentary <100; light 100-0027; moderate, 2020-5999 and vigorous, 6000+). NAFLD was defined as a fatty liver index >60 (FLI) in the absence of other chronic liver disease. Subjects with NAFLD were compared to controls using stratum-specific Chi-squared and t-tests. Simple linear regression analyses (with Taylor series linearised variance estimation and weighting) were used to determine the association between PA levels and NAFLD. P-values <0.05 were considered significant. Statistical analyses were conducted using sudaan version 10.1 and sas version 9.1.

RESULTS

We included 3056 participants. NAFLD patients were older, had higher BMI, larger waist circumference, higher sum of skinfolds, more likely to have insulin resistance (HOMA > 3.0) and type-2 diabetes (all P-values <0.01). Average PA for NAFLD subjects was about 28.7 counts/minute/day less than controls (P < 0.01). Furthermore, NAFLD subjects spent less time participating in activity at any level (P < 0.01). Subjects with NAFLD and DM were in the lowest quartile of average PA as well as moderate-vigorous PA (P < 0.01).

CONCLUSIONS

Data from this study show that non-alcoholic fatty liver disease patients have low level of physical activity and, when they have diabetes mellitus, they perform at the lowest quartile of physical activity and moderate-vigorous physical activity.

Anomalous origins of bilateral vertebral arteries in a child with Down syndrome and Moyamoya disease. A case report

Variations in vertebral artery origin and course are well-described in the literature. The origin of right vertebral artery from the right common carotid artery is an extremely rare variant. We describe a unique case of a child with Down syndrome with variant origins of bilateral vertebral artery, an aberrant right subclavian artery and concomitant Moyamoya disease of intracranial circulation. The presence of variations of the origin and course of craniocervical arteries might have profound implications in angiographic and surgical procedures and hence it is of great importance to be aware of such a possibility.

Viability kinetics, induction, resuscitation and quantitative real-time polymerase chain reaction analyses of viable but nonculturable Vibrio cholerae O1 in freshwater microcosm

AIM

To study the induction of a viable but nonculturable (VBNC) state in Vibrio cholerae O1 in freshwater, in response to cold temperatures (4°C) and starvation.

METHODS AND RESULTS

Vibrio cholerae O1 cells were inoculated in freshwater microcosm and incubated at 4°C. The cells became coccoid, rugose and subsequently nonculturable by day 16 on tryptic soy agar (TSA) and by day 23 on TSA-SP, while 87 and 65% of the cells retained their membrane integrity, respectively. Viable cells were observed until day 30 using direct fluorescent antibody-direct viable count method. In vitro resuscitation was demonstrated by temperature upshift. Utilizing 16S rRNA as an endogenous control, the DNA pol II (27·43-fold), fliG (12·44-fold), ABC transporter (27·11-fold), relA (60·76-fold) and flaC (15·29-fold) were significantly up-regulated in VBNC cells, while the expression of fadL-3 was comparable. The expression of DNA pol II, fliG, ABC transporter, relA and flaC was 3·3, 1·1, 5·9, 5·8 and 1·2-fold, respectively, for resuscitated cells. VBNC cells were found to be virulent, as ctxA and tcpA were expressed.

CONCLUSIONS

Vibrio cholerae undergoes both phenotypic alteration and genotypic modulation to protect itself from stress in freshwater.

SIGNIFICANCE AND IMPACT OF THE STUDY

Induction and resuscitation of the VBNC state in freshwater is important for an understanding of the epidemiology of cholera in the freshwater environment.

Distribution and ethnic variation of â-thalassemia mutations in Nepal

This is the first study characterizing spectrum of beta-thalassemia mutations in Nepalese population. Mutations were analyzed in 22 patients using 10 sets of allele-specific primers. Five of the mutations, namely F.S 41/42 (--TCTT), IVS1 nt5 (G-->C), IVS1 nt1 (G-->T), 619 bp deletion and F.S 8/9 (+G), were found to constitute 87.82% of total alleles studied. F.S 41/42 (--TCTT) was the commonest mutation. -88 (C-->T), Codon 16 (--C) and Codon 15 (G-->A), had a combined frequency of 12.18%. Distribution of mutations causing beta-thalassemia in different ethnic Nepalese groups was analyzed. The mutational profile in Nepal share several similarities with that from the two neighboring countries, India and China. Detection of more than one mutation in three cases of thalassemia trait raises the likelihood of existence of multiple mutations in cis in Nepalese thalassemic carriers. Such possibility has to be carefully considered while developing prenatal screening program for Nepalese population.

Environmental and epidemiological surveillance of Vibrio cholerae in a cholera-endemic region in India with freshwater environs

AIM

To conduct epidemiological and ecological surveillance of cholera in freshwater environments.

METHODS AND RESULTS

A freshwater region of India was surveyed between April 2007 and December 2008. Vibrio cholerae was isolated from 59·5% of water and plankton samples (n = 357) and 35·5% of stool samples (n = 290). Isolation from water was dependent on air (r = 0·44) and water temperatures (r = 0·49) (P < 0·01) but was independent of rainfall (r = 0·15), chlorophyll a (r = 0·18), salinity (r = 0·2) or pH (r = 0·2) (P > 0·05). Isolation from plankton was dependent on temperature of air (r = 0·45), water temperature (r = 0·44), chlorophyll a concentration (r = 0·42), pH (r = 0·23) and salinity (r = 0·39) (P < 0·01). Cholera cases correlated with rainfall (r = 0·82, P < 0·01) and chlorophyll a concentration (r = 0·42, P < 0·05), but not with air temperature (r = 0·3, P = 0·37). Vibrio cholerae O1 possessed ctxB, ctxA, rstR and tcpA (ElTor), toxR, toxT, rtxA, rtxC, mshA and hylA. Among non-O1-non-O139, the distribution of virulence-associated and regulatory protein genes was heterogeneous with - 0·7, 2·2, 94·77, 97·76, 99·25, 100 and 100% isolates being positive for tcpA, toxT, rtxA, rtxC, hylA, toxR and mshA, respectively. Two-thirds of non-O1-non-O139 isolates exhibited antibiotic resistance to various antibiotics that did not correlate with geographical site or time of origin for the isolates. RAPD and AFLP showed V. cholerae to be a diverse bacterium. AFLP demonstrated separate lineages for non-O1-non-O139 and O1 isolates.

CONCLUSION

Environmental parameters played a significant role in the emergence and spread of cholera and the abundance of V. cholerae. But based on virulence gene profiling and genetic fingerprinting, the possibility of origin of toxigenic isolates from nontoxigenic environmental isolates seems unlikely in freshwater environs of India.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study explains the ecology, epidemiology and seasonality of cholera in freshwater environs.

A naïve Gaussian Bayes classifier for detection of mental activity in gait signature

A probabilistic modelling is presented to detect mental activity from gait signature recorded from healthy subjects. The proposed scheme is based on principal component analysis with reduced feature dimension followed by a naïve Gaussian Bayes classifier. The leave-one-out cross-validation shows the detection accuracy of 94% with specificity and sensitivity of 96% and 98.3%, respectively. The research has a potential application in the prevention of elderly risk falls, lie detection and rehabilitation among Parkinson's patients.

RP - HPLC method for the estimation of Tamsulosin Hydrochloride in Tablet Dosage Form

A rapid and sensitive reverse phase RP-HPLC method is proposed for the estimation of tamsulosin hydrochloride in tablets. Tamsulosin hydrochloride was chromatographed on a reverse phase C18 column with a mobile phase consisting of acetonitrile and water in the ratio of 50:50 v/v. The mobile phase was pumped at a flow rate of 1.5 ml/min. The eluents were monitored at 214 nm. The retention time of the drug was 1.7 min. With this method, linearity was observed between area under curve and concentration of tamsulosin hydrochloride in the injected solution, in the range of 5 to 100 μg/ml. The method was found to be applicable for analysis of the drug in tablets. The results were validated statistically.

An in vitro paradigm for diabetic cerebral oedema and its therapy: a critical role for taurine and water channels

The pathophysiology of cerebral oedema (CE) in diabetic ketoacidosis (DKA) remains enigmatic. We investigated the role of the idiogenic osmol taurine and aquaporin channels in an in vitro model, the SH-SY5Y neuroblastoma cell line, by sequentially mimicking DKA-like hyperglycemia/hypertonicity and hypotonic fluid therapy. Exposure to DKA-like hyperosmolarity led to shrinkage, while hypotonic fluid exposure led to cell swelling and impaired viability. Low sodium compensated in part for elevated glucose, pointing to a critical role for overall osmolality. Taurine, was synthesized and retained intracellularly during DKA-like hypertonicity, and released during hypotonicity, in part mitigating neuronal swelling. Metabolic labeling showed that the rate of taurine release was inadequate to fully prevent neuronal swelling during hypotonic fluid therapy following DKA-like hypertonicity. Under these conditions, Aquaporin4 & 9 channels were respectively down and up-regulated. Our study provides further novel insights into molecular mechanisms contributing to CE in DKA and its therapy.

Condyloma acuminatum: atypical presentation during pregnancy

Genital warts (condylomata acuminata) are caused by human papillomavirus (HPV) and are usually transmitted sexually. We present an atypical case of a vaginal wart presenting as a single pedunculated mass protruding outside the vagina in a pregnant woman in labour. On examination of the vulva, a soft, pink papilliferous growth of 6 × 4 cm size was seen hanging outside the vaginal introitus. Speculum examination revealed that the growth was attached to the posterior and lateral vaginal wall near the fornix. Genital warts can proliferate during pregnancy due to altered immunity and increased blood supply, as seen in this case. Vaginal warts can also cause problems during delivery, since they prevent the vagina from stretching appropriately.

Preliminary investigation of foot pressure distribution variation in men and women adults while standing

BACKGROUND

Women and men are anatomically and physiologically different in a number of ways. They differ in both shape and size. These differences could potentially mean foot pressure distribution variation in men and women. The purpose of this study was to analyze standing foot pressure image to obtain the foot pressure distribution parameter - power ratio variation between men and women using image processing in frequency domain.

METHODS

We examined 28 healthy adult subjects (14 men and 14 women) aged between 20 and 45 years was recruited for our study. Foot pressure distribution patterns while standing are obtained by using a PedoPowerGraph plantar pressure measurement system for foot image formation, a digital camera for image capturing, a TV tuner PC-add on card, a WinDvr software for still capture and Matlab software with dedicated image processing algorithms have been developed. Various PedoPowerGraphic parameters such as percentage medial impulse (PMI), fore foot to hind foot pressure distribution ratio (F/H), big toe to fore foot pressure distribution ratio (B/F) and power ratio (PR) were evaluated.

RESULTS

In men, contact area was significantly larger in all regions of the foot compared with women. There were significant differences in plantar pressure distribution but there was no significant difference in F/H and B/F ratio. Mean PR value was significantly greater in men than women under the hind foot and fore foot. PMI value was greater in women than men. As compared to men, women have maximum PR variations in the mid foot. Hence there is significant difference at level p<0.05 in medial mid foot and mid foot PR of women as compared to men.

CONCLUSION

There was variation in plantar pressure distribution because the contact area of the men foot was larger than that of women foot. Hence knowledge of pressure distributions variation of both feet can provide suitable guidelines to biomedical engineers and doctor for designing orthotic devices for reliving the area of excessively high pressure.

Prevalence and associations of hepatitis C viremia in hemodialysis patients at a tertiary care hospital

Hepatitis C virus (HCV) infection in hemodialysis (HD) is a significant problem. We evaluated the prevalence and associations of HCV viremia in our HD patients. All patients undergoing maintenance HD at our center were tested for HCV RNA by PCR after written informed consent. Detailed history regarding age, sex, and duration of dialysis, frequency of dialysis, blood transfusions in one year, number of dialysis centers, dialyzer reuse/fresh use, and recent laboratory data was recorded. A total of 119 patients (77 males and 42 females) were tested for HCV RNA. Thirty three (27.7%) tested positive. Duration of dialysis was significantly longer in HCV RNA positive group (P = 0.001). 45.2% of patients with duration of dialysis more than 16 months were HCV RNA positive while only 7.4% of patients with dialysis duration ≤16 months were HCV RNA positive (P < 0.001). In univariate analysis, in HCV RNA group patients, ALT, AST, and GGTP were significantly elevated and albumin was significantly lower. 39% of patients who had dialysis at more than one center were HCV RNA positive as compared to 20% for patients undergoing dialysis at single center (P = 0.024). Binary logistic regression analysis showed albumin, duration of dialysis, and serum ALT to be significant variables. Sensitivity and specificity of anti-HCV ELISA was 72.7 and 97.7%, respectively. Prevalence of HCV RNA in the HD population is 27.7%. Duration of dialysis, getting dialysis at more than one center, elevated transaminase levels, and low serum albumin are important associations for HCV RNA positivity.

Antibacterial Activity of Ethanol Extract of Andrographis paniculata

In the present study the ethanol extract of the aerial part of Andrographis paniculata was prepared and evaluated for antimicrobial activity against eleven bacterial strains by determining minimum inhibitory concentration and zone of inhibition. Minimum inhibitory concentration values were compared with control and zone of inhibition values were compared with standard ciprofloxacin in concentration 100 and 200 μg/ml. The results revealed that, the ethanol extract is potent in inhibiting bacterial growth of both Gram-negative and Gram positive bacteria.

Effect of caffeine and taurine on simulated laparoscopy performed following sleep deprivation

Background

Sleep deprivation affects surgical performance and has the potential to endanger patient safety. Pharmacological stimulants may counter this consequence of long working hours. This study aimed to investigate whether commonly available stimulants can counter the effects of fatigue on technical and neurocognitive skill.

Methods

This was a single-blind crossover study of surgical novices trained to proficiency on the Minimally Invasive Surgical Trainer—Virtual Reality laparoscopic simulator. Participants were acutely sleep-deprived three times each, followed by administration of either placebo, 150 mg caffeine, or 150 mg caffeine combined with 2 g taurine before simulated laparoscopy. Outcome measures were: laparoscopic psychomotor skill, cognitive performance and the Stanford Sleepiness Scale (range 1–7). Rested baselines were gathered following completion of test sessions.

Results

Baseline performance was recorded for 18 participants in the rested state. Sleep-deprived participants receiving the placebo took longer (median 41 versus 35 s; P = 0·016), were less economical with movement (3·25 versus 2·95 m; P = 0·016) and made more errors (66 versus 59; P = 0·021) on the laparoscopic task compared with the rested state. Caffeine restored psychomotor skills to baseline for time taken (37 versus 35 s; P = 0·101), although the number of errors remained significantly greater than in the rested state (63 versus 59; P = 0·046). Sleep-deprived subjects receiving placebo had slower reaction times (377 versus 299 ms; P = 0·008) and a higher score on the Stanford Sleepiness Scale (6 versus 2 points; P = 0·001) than rested surgeons. Negative effects of sleep deprivation on reaction time were reversed when caffeine (307 ms versus 299 ms in rested state; P = 0·214) or caffeine plus taurine (326 versus 299 ms; P = 0·110) was administered. Subjective sleepiness was also improved, but not to baseline levels.

Conclusion

Sleep deprivation affects laparoscopic psychomotor skills, reaction time and subjective measures of sleepiness in novice surgical subjects. Caffeine and taurine restore simulated laparoscopic performance to rested levels, but do not reduce errors.

A randomized clinical trial to compare the efficacy of different doses of intravaginal misoprostol with intracervical dinoprostone for cervical ripening and labor induction

OBJECTIVES

To compare the efficacy of 25 vs. 50 microg of intravaginal misoprostol vs. intracervical dinoprostone for cervical ripening and labor induction.

MATERIALS AND METHODS

210 women with Bishop's score <6 were randomized into 3 groups of 70 each to receive 6 hourly doses of either 25 or 50 microg of intravaginal misoprostol or 0.5 mg intracervical dinoprostone to maximum of 3 doses and outcome parameters were compared.

RESULTS

Induction to vaginal delivery interval was significantly lower (p < 0.05) for 50 microg (13.8 +/- 6.62 hours) as compared to 25 microg misoprostol (16.4 +/- 7.34 hours) or dinoprostone group (16.3 +/- 7.49 hours). Maximum improvement (p < 0.05) in Bishop's score and minimum oxytocin requirement (p < 0.05) was seen with misoprostol 50 microg. No significant difference was observed for women delivering vaginally within 24 hours (93.8 vs. 89.7 vs. 85.4%), patients delivering after one dose (24.3 vs. 21.4 vs. 20%), cesarean deliveries, fetal outcome, complications like hyperstimulation and fetal heart abnormalities for the 50 vs. 25 microg misoprostol vs. dinoprostone group.

CONCLUSION

Intravaginal misoprostol 50 microg administered 6 hourly appears to be most effective as it has least induction to delivery time, has maximum improvement in Bishop's score, least oxytocin requirement without any increase in complication rate.

Intra-lesional steroid for the management of symptomatic Infantile Digital Fibromatosis

BACKGROUND

Infantile Digital Fibromatosis (IDF) is a benign, often asymptomatic nodular proliferation of fibrous tissue occurring almost exclusively on the extremities. Conventional treatment has included radical surgery but this is associated with a high level of recurrence. Whilst some authors suggest a strictly conservative approach, this is unacceptable when lesions become symptomatic from pain, contracture formation or functional deformity

METHODS

We present a retrospective analysis of 12 symptomatic lesions of which 7 were treated with a novel technique of intra-lesional steroid. From 2004-2009, a total of ten patients received treatment for symptomatic IDFs. Patients were followed-up for an average of 5 years 9 months (range 8-131 months).

RESULTS

Corticosteroid was well tolerated with no significant complications and was associated with lower morbidity that compared with surgery. There was no significance difference between rate of recurrence (1/7 vs. 5/10) for those treated with corticosteroid than compared to those patients who underwent surgery (p = 0.3) but the study is underpowered.

CONCLUSIONS

This is the first ever study to look at the role of intra-lesional steroid in the management of IDF. Whilst the majority of asymptomatic Infantile Digital Fibromatoses can be safely observed until natural resolution, intra-lesional corticosteroid is a safe and well-tolerated alternative to surgery for all symptomatic digital fibromatoses of infancy. We suggest it replaces surgery as first-line treatment but look forward to a large multicentre trial to allow comparison.

Demonstration of viable but nonculturable Vibrio cholerae O1 in fresh water environment of India using ciprofloxacin DFA-DVC method

AIM

To demonstrate the presence of culturable and nonculturable viable pathogenic Vibrio cholerae O1 in fresh water environments of a cholera-endemic region in India.

METHODS AND RESULTS

Conventional culture and ciprofloxacin DFA-DVC were utilized to investigate the existence of V. cholerae O1. We isolated pathogenic culturable V. cholerae O1 from water samples collected from cholera-affected areas. No culturable V. cholerae O1 was isolated from water and plankton samples from natural fresh water bodies. Ciprofloxacin was used for DFA-DVC as V. cholerae O1 are 100% resistant to nalidixic acid in our region. The viable but nonculturable O1 cells were demonstrated in 2.21 and 40.69% samples from natural water bodies and cholera-affected areas, respectively.

CONCLUSION

Vibrio cholerae O1 VBNC could be demonstrated using modified DFA-DVC technique. Ciprofloxacin is preferable to nalidixic acid for DVC in view of existing high-level resistance to nalidixic acid in cholera-endemic areas.

SIGNIFICANCE AND IMPACT OF THE STUDY

We endorse that for public health surveillance, cholera outbreak investigation and disease control water samples in addition to culture should be tested for V. cholerae using DFA-DVC.

Occurrence of Gnathostoma spinigerum in free range tigress

Postmortem examination of free-range tigress of Pench Tiger Reserve, MP, India, aged approx 15 years revealed nodule in the pyloric part of the stomach packed with worms and was identified as Gnathostoma spinigerum on the basis of morphology of male and female worms, including eggs.

Travails of self-manipulation of a catheter

A large number of patients suffer from Stage 5 chronic kidney disease (CKD). One of the treatment options used in these patients is continuous ambulatory peritoneal dialysis (PD), which is known to improve patient quality of life. 15-50% of Stage 5 chronic kidney disease patients are on PD in the USA. The PD catheter maybe inserted into the abdominal cavity by a surgeon, an interventional radiologist or a nephrologist. We report the most unusual case of an adult patient who reinserted the slipped PD catheter himself leading to an "unseen before" complication.