Autoimmune Thyroid Disease in Psoriasis Patients: A Case-Control Study

INTRODUCTION

Psoriasis is a common immunologically mediated inflammatory disease characterized by skin inflammation, epidermal hyperplasia, an increased risk of painful and destructive arthritis, cardiovascular morbidity, and psychosocial challenges. Some autoimmune diseases are mediated by stimulating or blocking auto-antibodies. Auto-antibodies may act as antagonists and bind to hormone receptors, blocking receptor function. It may result in impaired secretion of mediators and gradual dysfunction of the affected organ, e.g., Graves disease and myasthenia gravis.

OBJECTIVE

This study was planned to evaluate the association between anti-thyroid peroxidase antibody (anti-TPO Ab) and anti-thyroglobulin antibody (anti-TG Ab) as biochemical markers in 30 clinically diagnosed psoriasis patients.

MATERIALS AND METHODS

This hospital-based, epidemiological case-control study was conducted in the Department of Biochemistry in collaboration with the Department of Dermatology, Venereology, and Leprology at Bhagat Phool Singh Government Medical College for Women, Khanpur Kalan, Sonepat, Haryana, India. Thirty subjects diagnosed clinically with psoriasis and an equal number of age-matched controls with no known autoimmune disease from the outpatient department were also enrolled. The following hormonal tests, i.e., thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), free thyroxine (FT4), and antibodies, anti-TPO Ab and anti-TG Ab, were performed. The study period was one year. The data thus obtained was analyzed using SPSS Statistics version 26.0 (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp). The significance level (p-value) was taken as <0.05.

RESULTS

The mean age of psoriasis subjects was 37.83±12.89 years compared to 36.91±12.32 years in the control group and was found to be non-significant (p=0.432), reflecting a similar age distribution. A male preponderance was observed in the present study, where the psoriasis group consisted of 80% males and 20% females, while the control group had 60% males and 40% females. All six psoriasis patients diagnosed with autoimmune thyroid disease (AITD) were euthyroid at the time of enrollment, compared to only one control subject in a subclinical hypothyroid state. The mean values of anti-TPO Ab were 30.93±41.26 IU/mL in psoriasis patients and 11.39±28.42 IU/mL in the control group (p=0.001), while the mean values of anti-TG Ab were 11.21±27.69 IU/mL in psoriatic subjects and 2.49±9.05 IU/mL in the control group (p=0.004). No significant correlation between AITD and psoriasis was found when both parameters were analyzed statistically for correlation; even when one marker was considered, no significant correlation was found. The odds ratio was calculated to find an association between the disease and thyroid autoimmunity. The odds ratio was estimated to be 2.25 for psoriasis and the control group, with a confidence interval of 95% (0.77-6.59) and a p-value of 0.139, which was not statistically significant.

CONCLUSION

Psoriasis, a dermatological disorder, has been seen as related to AITD. The role of early detection of anti-thyroid antibodies, i.e., anti-TPO Ab and anti-TG Ab, can be of prognostic value in AITD and psoriasis.

Indispensable Role of Transesophageal Echocardiography in Double-Chamber Right Ventricle Repair Surgery

Double-chamber right ventricle repair surgery requires the excision of anomalous obstructive muscular or fibromuscular bundles in the right ventricular outflow tract. Because of the close proximity of key structures in the right ventricular outflow tract, the surgery is extremely challenging and requires precise resection. Underresection of the muscle bands can lead to significant residual gradients in the postoperative period, whereas overenthusiastic resection can cause iatrogenic injury to surrounding structures. Various techniques like Hegar sizing by the surgeons, direct chamber pressure measurement, transesophageal echocardiography, and epicardial echocardiography can guide the surgeons about the adequacy of repair. Transesophageal echocardiography is crucial at each step, as it can precisely determine the exact site of obstruction in the preoperative period. Postoperatively, it helps determine the adequacy of surgical repair and identification of inadvertent iatrogenic complications.

Thyroid Autoimmunity in Vitiligo: A Case-Control Study

Introduction There is scanty evidence regarding the role of autoimmunity in vitiligo, especially in the Asian population. Moreover, the existing studies reported conflicting results. This prompted the investigators to identify the association of thyroid autoimmunity with vitiligo by employing a case-control design in this setting. Methodology The present study was a hospital-based case-control study conducted in one of the tertiary care hospitals of North India. We recruited 30 subjects aged 16-60 years with vitiligo attending the skin and venereal diseases outpatient department. The subjects attending the general medicine outpatient department without having a diagnosis of vitiligo were considered for the control group. Thyroid hormones (FT3 and FT4), thyroid-stimulating hormones, anti-thyroid peroxidase (anti-TPO) antibodies, and anti-thyroglobulin (anti-TG) antibodies were the primary investigations performed among the study subjects. Results The mean age of the study subjects was 31.3 (SD: 13.3) years. Both the case and control groups were comparable based on selected socio-demographic variables (p > 0.05). There was a statistically significant difference in terms of mean anti-TPO and anti-TG values between the case and control groups in which subjects with vitiligo reported significantly higher values (p < 0.05). Conclusion Our study reported a significant elevation in the mean values of the thyroid antibodies (anti-TG and anti-TPO antibodies) in vitiligo subjects compared to control subjects in this setting. Hence, screening for autoimmune thyroid diseases among patients with vitiligo is suggested for the early detection and the initiation of appropriate intervention.

A cross sectional observational study on the effect of music on the anxiety state of patients admitted for COVID 19 in a tertiary care hospital in New Delhi

Introduction

COVID 19 has led to dramatic changes in the lives of people leading to an increase in stress and anxiety. Music intervention is a non-medicated method for relieving anxiety. This current study aims to understand whether music can be effectively used to alleviate anxiety in admitted COVID-19 patients.

Objectives

To study the effect of music on anxiety in patients admitted for COVID-19 in a tertiary care hospital in New Delhi

Methods

34 patients (17 females &17 males) were randomly divided into two groups, a control (N=17) and a music group (N=17). Vitals of all the patients were noted. Patients of the music group were asked to listen to relaxing instrumental for 30 minutes, while patients of the control group were asked to relax for 30 minutes. Vitals of all the patients were noted again. Patients were asked to fill State Trait Anxiety Inventory (STAI) before and after intervention.

Results

The post-intervention mean scores of STAI after the music session were lower in the music group than the control group [95.06 (SD 8.5)) versus 102.37 (SD 10.3)]. The differences in mean values of pre- to post-intervention changes between both groups after music session were statistically significant.

Conclusions

Our findings suggest that listening to music lowers anxiety. As music is non- invasive and free of side-effects we recommend that music intervention service should be used to improve health care quality.

Disclosure

No significant relationships.

Successful Management of Caesarean Scar Ectopic Pregnancies: A Report of Five Cases

Background:

Cesarean section scar ectopic pregnancy (CSEP) is a rare and potentially life-threatening condition. A standardized management protocol is yet to be established owing to limited data available.

Case Presentation:

In this paper, five cases of CSEP over a period of 18 months at a tertiary referral hospital, managed medically with methotrexate administered both systemically and into the gestational sac at the time of feticide with potassium chloride (KCL) are presented. Surgical management was the second line therapy when medical treatment failed.

Conclusion:

With rising trends in cesarean deliveries, CSEP may be a challenge which requires close investigation regarding its diagnosis and treatment on the merits of case studies and available healthcare facilities.

Comparison of Bone-Patellar Tendon-Bone Graft, Semitendinosus-Gracilis Graft and Semitendinosus-Gracilis with Preserved Tibial Insertion Graft in Anterior Cruciate Ligament Reconstruction in Sports Persons

Introduction

Bone-patellar tendon-bone (BPTB) and semitendinosus-gracilis (STG) are the commonest grafts used for ACL reconstruction. However even after having been debated for years, there is no consensus about the ideal graft. Moreover, the literature is deficient about STG graft with preserved tibial insertion (STGPI) which preserves the proprioception. Our aim is to compare the outcome of BPTB, free STG and STGPI grafts after ACL reconstruction in professional sports persons. We compared the outcome in terms of mechanical stability, functional outcome, return to sports activity and degenerative changes.

Material and Methods

Professional sports persons aged between 16-50 years operated for ACL tear using BPTB, free STG and STGPI grafts with minimum follow-up of two years were identified from hospital records. Patients with associated knee injuries were excluded. Patients, divided in three groups according to graft used, were compared in terms of mechanical stability (arthrometric examination KT-1000 score), functional outcome (Lysholm Score), return to sports activity (Tegner score and difference in thigh circumference) and degenerative changes (KL grading).

Results

BPTB graft group was found to be better than free STG and STGPI graft groups in terms of KT-1000 score. There was no statistically significant difference among the groups in terms of Lysholm score, Tegner score, difference in thigh circumference and KL grading.

Conclusion

BPTB graft is better than free STG and STGPI grafts in terms of knee stability. When compared for patient reported outcome, return to sports activity, osteoarthritic changes and graft failure there is no significant difference among the three types of grafts.

POS0805 TREATMENT OF GIANT CELL ARTERITIS WITH TOCILIZUMAB: A RETROSPECTIVE COHORT STUDY OF 119 PATIENTS

Background:

Giant cell arteritis (GCA) is an inflammatory condition of medium- and large-sized arteries. Prospective clinical trials have demonstrated the efficacy of tocilizumab (TCZ) for treatment of patients with GCA (1). However, there is a limited data on the use of TCZ in routine clinical practice.

Objectives:

To evaluate the efficacy and safety of TCZ in a retrospective cohort study of patients with GCA treated with TCZ.

Methods:

Patients with GCA treated with TCZ at 4 clinical centers of a single tertiary care institution (2000-2020) were identified. The diagnosis of GCA was confirmed by at least one of the following modalities: 1. Arterial biopsy 2. Large vessel imaging 3. Clinical diagnosis of GCA meeting ACR classification criteria and established by a rheumatologist. Patient demographics, clinical presentation, laboratory studies, treatment course and adverse events were abstracted from the medical record; only patients with at least 6 months of follow-up after TCZ initiation were included. Kaplan-Meier methods were used to estimate time to TCZ discontinuation and time to first relapse after TCZ discontinuation. Poisson regression models were used to compare relapse rates before and after TCZ initiation.

Results:

The study cohort included 119 patients [61% female; mean (SD) age at GCA diagnosis 70.3 (8.2) years]. The majority of patients (89%) had a biopsy-proven and/or imaging-based diagnosis of GCA, while 13 (11%) had a clinical diagnosis of GCA. In addition to glucocorticoids, 40 (34%) patients received other immunosuppressive agents prior to TCZ. The method of initial TCZ administration was subcutaneous (162mg/ml) weekly in 48 (41%), subcutaneous every other week in 20 (17%), monthly 4mg/kg infusions in 34 (29%), monthly 8mg/kg infusions in 14 (12%) and non-standard dosing in 3 remaining patients. The median (IQR) duration from GCA diagnosis to TCZ initiation was 4.8 (1.2-22.0) months and the median (IQR) duration of TCZ treatment was 18 (11-28) months. The mean (SD) dose of prednisone at TCZ initiation was 31 (19) mg/day and was reduced to a mean (SD) dose of 3.9 (6.7) mg/day at TCZ discontinuation/last follow-up visit. The relapse rate per year decreased 43% from 0.77 to 0.44 after the initiation of TCZ (RR=0.57; 95% CI: 0.44-0.75; p<0.001). The mean (SD) ESR and CRP decreased from 22 (20) mm/hour to 6 (9.2) mm/hour and from 19.1 (25) mg/L to 5.4 (16.6) mg/L, respectively from TCZ initiation to TCZ discontinuation/last follow-up visit. At 2 years of follow-up, 67% of patients had discontinued glucocorticoids. At last follow up, 46 patients had discontinued TCZ, only 14 of which were due to adverse events. The median time to TCZ discontinuation was 2.9 years. Only 17% (95%CI: 10-24%) had discontinued by 1 year after TCZ initiation and 38% (95% CI: 26-47%) had discontinued by 2 years. The most common adverse events were infections and cytopenias. While on TCZ, 1 patient developed new onset vision loss related to GCA and 1 patient, without history of diverticulitis, had bowel perforation. Among those discontinuing TCZ, 61% had relapsed at least once by 1 year after TCZ discontinuation.

Conclusion:

In this large single institution cohort of patients with GCA, TCZ use resulted in a significantly reduced relapse rate and reduction in glucocorticoid dosage. Overall, patients tolerated long-term use with only 12% discontinuing due to adverse events. However, over half of patients stopping TCZ had a subsequent flare; highlighting ongoing use may be required beyond two years in several patients with GCA to maintain remission.

References:

[1]Stone JH, et al. Trial of Tocilizumab in Giant-Cell Arteritis. N Engl J Med. 2017 Jul 27;377(4):317-328. doi: 10.1056/NEJMoa1613849. PMID: 28745999.

[2]Calderón-Goercke M, et al. Tocilizumab in giant cell arteritis. Observational, open-label multicenter study of 134 patients in clinical practice. Semin Arthritis Rheum. 2019 Aug;49(1):126-135. doi: 10.1016/j.semarthrit.2019.01.003. Epub 2019 Jan 5. PMID: 30655091.

Disclosure of Interests:

Jigisha Rakholiya: None declared, Matthew Koster: None declared, Hannah Langenfeld: None declared, Cynthia S. Crowson: None declared, Andy Abril: None declared, Pankaj Bansal: None declared, Lester Mertz: None declared, Alicia Rodriguez-Pla: None declared, Rahul Sehgal: None declared, Benjamin Wang: None declared, Kenneth J Warrington Grant/research support from: Research support: Kiniksa, Eli Lilly

Practical consensus recommendations for gestational breast cancer

This manuscript provides a practical and easy to use consensus recommendation to community oncologists on how to manage gestational breast cancer.

Embelin modulates metabolic endotoxemia and associated obesity in high fat diet fed C57BL/6 mice

The present study was designed to investigate the effect of embelin in metabolic endotoxemia (ME) mediated inflammation and associated obesity in high fat diet (HFD)-fed C57BL/6 mice. The molecular docking of embelin confirms its binding with the toll-like receptor-4 (TLR-4). In vivo study, mice were treated with HFD for 8 weeks to induce ME mediated inflammation and associated obesity. Further, mice were treated with embelin (50 and 100 mg/kg/day, p.o.) and orlistat (10 mg/kg/day, p.o.) from 5th to 8th week along with HFD to improve associated changes. After 8 weeks, mice were euthanized and assessed for body weight, body mass index (BMI), fat pad weights (mesenteric, retroperitoneal, and epididymal), intestinal permeability, TLR-4, tumor necrosis factor-α, interleukin-6, lipopolysaccharide, and serum lipid levels followed by histopathological analysis of liver and adipose tissues. Embelin significantly decreased the body weight, BMI, serum lipid levels, ME, and inflammation manifested by above parameters. Further, results of histopathological study showed that embelin restored the vacuolization, inflammation, one side shifting of nucleus in liver tissue, and decreased adipocyte cells size in adipose tissue in HFD-fed mice. Thus, our findings provide the strong evidence first time that embelin could modulate ME, mediate inflammation, and consequently reduce body weight gain, BMI, and serum lipid levels in HFD-fed mice.

Isolation of lupenone (18-Lupen-3-one) from Roscoea purpurea root extract

Background: Endangered plant “Kakoli” is important component of Ashtwarga group of plants and anti-aging Ayurvedic preparations. Due to limited supply of original plant, official substitutes and common adulterants are being used by drug manufacturers. There is a need to identify a marker compound that could differentiate original plant from substitutes and common adulterants. Objective: To isolate and characterize the marker compound from roots of this plant. Material and methods: The extract of plant root was prepared in methanol and marker compound was isolated from methanol extract through column chromatography by using silica gel (60–120 mesh size) in glass column (1000mm x 50mm). The compound was obtained in fractions numbered 990-1550 and isolated by cutting and pooling of TLC plate of compound having Rf = 0.52 by the use of mobile phase toluene: ethyl acetate: formic acid (9.5: 0.5: 0.1 v/v/v). Compound was characterized by using IR, NMR, Mass and UV spectroscopy. Results: The methanol extract was blackish brown in color and showed the presence of alkaloids, terpenoids, phytosterols, flavonoids, phenolics and amino acid. The isolated compound was found to be colorless terpenoid needle with m.p. 168-171°C; [α]D +62.8° (c 1.0,CHCl3). Spectral analysis confirmed presence of lupenone. Conclusion: In present study lupenone was isolated for the first time from Kakoli. None of adulterants and substitutes of Kakoli are reported to have lupenone hence can be used as marker for identification as well as differentiation of the plant from official substitutes and common adulterants. Bangladesh Journal of Medical Science Vol.19(4) 2020 p.692-696

Was Hawan Designed to Fight Anxiety-Scientific Evidences?

Anxiety is a psychiatric disorder with unknown neurobiology; however, neurotransmitters like gamma-amino butyric acid, norepinephrine and serotonin (5-HT) play crucial roles in mediating anxiety. Present drug modules pose dependence risk to the patient; hence, there is a great need to develop complementary therapies to fight this disorder. Aromatherapy has also been employed in ancient times for a number of mental disorders. Mahamrituanjay Mantra, Om triambkum yajamahe, sughandhim puushtivardhanam, urvarukmev vandhanaat, mrityu mokshay mamritaat!!!!, the part of veda enlightens that aroma gives rise to good health (sughandhim puushtivardhanam). Hawan is a religious practice recommended for mental peace. Hawan is a process in which special herbs are offered in the fire of medicinal woods ignited in a specially designed fire pit. Analysis of literature demonstrates that the components of Hawan are having a number of volatile oils that are specifically useful for prevention and treatment of anxiety through some mechanism of action. Due to high temperature of fire, the vapors of these oils from herbs enter into the central nervous system through nasal route. As per modern science and ancient texts on medicine, nasal drug delivery systems are the best for the diseases related to brain and head. The routine of performing Hawan might keep the threshold value of the therapeutic components in the body and help in preventing anxiety. In the present manuscript, authors highlight and integrate the modern and ancient concepts for treatment and prevention of anxiety through scientific evidences.

Elemental impurities in pharmaceutical products adding fuel to the fire

The pharmaceuticals may generate impurities at various stages of development, transportation and storage which make them risky to be administered. Thus, it is essential that these impurities must be detected and quantified. However, their presence as impurities in finished products is virtually unavoidable, even under GMP conditions. Control of elemental impurities in pharmaceutical materials is currently undergoing a transition from control based on concentrations in components of drug products to control based on permitted daily exposures in drug products. Within the pharmaceutical community, there is uncertainty regarding the impact of these changes on manufactures of drug products. This uncertainty is fueled due to lack of publicly available information on elemental impurity levels in common pharmaceutical excipients. The present compilation gives an account of updated information about elemental impurities and reviews the regulatory aspects for such impurities in active pharmaceutical ingredients/drug formulations. In addition, the aim of this article is to review and discuss the currently used quantitative analytical method, which is used for quality control of elemental impurities in pharmaceutical products.

Recycling waste thermoplastic for energy efficient construction materials: An experimental investigation

A large stream of research has studied the performance of waste plastics impregnated concrete, reporting multiple benefits and advocating its use in construction works. But no study has reported the merits of bricks impregnated with waste plastics. The present paper reports the results of experiments done on bricks made up of varying percentages of waste thermoplastics (0 - 10% by weight) and sand (60 - 70% by weight), holding percentages of fly ash and ordinary Portland cement constant at 15% (by weight) each. Three types of waste thermoplastics were used, forming three separate batches of bricks. The plastics were polycarbonates, polystyrenes, and mixed plastics. The bricks were cured under water for 28 days. Some of the batches were baked at temperatures ranging from 90 °C to 110 °C for 2 hours in order to melt the plastics to form voids. The bricks made with the above-stated compositions were found to possess low thermal conductivity and adequately high compressive strength. The compressive strength of these bricks is observed to be more than 17 MPa, which lies within the upper half of the range of strengths specified for bricks in the IS 1077:1992 standard. The waste plastics impregnated bricks display high thermal resistance, a feature that can add economic value to the brick manufacturers, motivating them to establish the necessary logistics for collection and use of all types of waste thermoplastics. The paper also presents a regression model to predict the compressive strength of bricks at varying plastic contents. The study, thus, introduces a new strand of research on sustainable recycling of waste thermoplastics in the context of the circular economy.

Assessment of compliance level of ICH guidelines for organic volatile impurities in common ayurvedic hepatic formulations

Background Herbal medicines have been used in the treatment of liver diseases for a long time. In recent years, the use of herbal medicines for protection from other strong antibiotics as well as drugs that can damage the liver during their metabolism in liver and for treatment of liver diseases has increased all over the world. It is important to mention that a number of organic solvents are used at different stages of extraction/formulation development for these traditional preparations in industries/pharmacies. In addition, some of these solvents possess established carcinogenic properties and may enter the formulation as residual solvents. Hence as per ICH guidelines it is mandatory to keep the level of these solvents up to permissible limits. There has been a lot of hue and cry that ayurvedic formulations available in the market are not properly standardized for their quality due to lack of stringent regulations and standards from regulatory authorities. Therefore the aim of present work was to assess the compliance of ICH guidelines for level of organic volatile impurities in common marketed ayurvedic hepatic formulations. Methods In this study, 25 ayurvedic herbal formulations available as OTC product have been assessed for presence of residual solvents using gas chromatography with flame ionization detector. Results This study on 25 fast moving hepatic formulations in the market reflects that no residual solvents were detected in any of the formulations however if present were within prescribed permissible limits of ICH guidelines. The data was also subjected to statistical analysis (F-test and t-test at 95% confidence level). Conclusions Results indicate the safety of these hepatic formulations with respect to residual solvents. In addition presents a simple, linear, specific, accurate, precise and rugged gas chromatographic method for estimation of residual solvents.

The Role of GnRH Analogues in Improving Outcome in Women Undergoing Superovulation and Intrauterine Insemination after Surgical Correction of Mild Endometriosis: A Randomized Controlled Trial

Objective

Treatment with laparoscopic surgery, gonadotropin-releasing hormone analog (GnRHa) therapy, superovulation (SO), and intrauterine insemination (IUI) have individual benefits in improving fertility outcomes in women with endometriosis. The aim of the study was to evaluate the role of GnRHa in improving outcome in women undergoing SO and IUI after surgical correction of mild endometriosis.

Materials and Methods

This was a randomized controlled trial conducted in the Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India, over a period of 2 years and 6 months. Ninety women who were diagnosed with mild endometriosis on laparoscopy using the revised American Society for Reproductive Medicine criteria were included in the study. The patients in the study group (n=45) received a single dose of 3.75 mg GnRHa subcutaneously within 48 h of the surgery, and those in the control group (n=45) did not receive GnRHa. Thereafter, patients in both arms received SO and IUI from the next menstrual cycle. Four patients in the study group and three patients in the control group were lost to follow-up before the first cycle of ovulation induction. Primary outcomes measured in our study were live birth rates and clinical pregnancy rate. Secondary outcome measures were number of follicles >18 mm, endometrial thickness, dose and days of gonadotropin stimulation.

Results

Baseline characteristics, such as age and body mass index, were comparable in both groups. The SO and IUI cycles were comparable between the two groups with regard to the secondary outcome parameters. Pregnancy rate in the first cycle was 17.1% in the study group and 19.1% in the control group (p=0.81). The overall pregnancy rate was similar in both groups (study group=21.9%, control group=23.8%; p=1). As no patient had miscarriage or any other complication during pregnancy, live birth rate was similar to the clinical pregnancy rate.

Conclusion

Adding GnRHa for the suppression of mild endometriosis has shown no significant improvement in the surgical management of women undergoing SO and IUI.

Health care seeking behavior of parents of under five in District Kanga, Himachal Pradesh

Background: Health seeking behavior denotes the process involved in seeking a particular health state. Whereas, the healthcare seeking behavior of any individual denotes the end point contact of care. The objectives of the study were to understand the health seeking behavior and health care seeking behavior of parents of children, 0-5 yrs of age in Himachal Pradesh.Methods: A community based cross- sectional study on 2400 children of age less then and equal to 59 months was conducted. Morbidity profile and socio demographic indicators along with other variables were defined as indicators of health and health care seeking behaviour. The study was conducted using 30 cluster techniques with 80 participants from each cluster of district Kangra. Results: Water and sanitation was taken as one of the indicators of health seeking behavior and majority of our study population was dependent on ‘bavdi’ as water source. Earthen and steel pots were the most sought after storage vessel. In slums however plastic buckets were used. More than 80% of the households did nothing for purification. Majority responded that (82.6%) their child took bath daily. Institutional delivery was prevalent among 81.2% cases and lowest among rural slum. Nutrition was also taken as an indicator. Exclusive breast feeding was prevalent in 51.1% cases. In case of health care seeking behavior in our study around 47.0% parents visited the health facility, but also 24.0% were dependent on home remedies. Majority (30.5%), took treatment from secondary level of health care followed by 28.4% from private Ayurvedic Doctor. Conclusions: The system needs to understand its weaknesses as to why the population still practices unsatisfactory behavior across various areas. Especially in case of institutional deliveries, breast feeding and seeking treatment from a quack. 

Development and validation of a stability-indicating RP-HPLC method for simultaneous determination of dapagliflozin and saxagliptin in fixed-dose combination

A simple and precise stability indicating method for the simultaneous estimation of dapagliflozin and saxagliptin in combined tablet dosage form was developed and validated using RP-HPLC.

Hypopituitarism presenting as congestive heart failure

Sheehan's syndrome (SS) develops as a result of ischemic pituitary necrosis due to severe postpartum hemorrhage and is characterized by various degrees of hypopituitarism. Although the occurrence of SS is now rare, it should still be considered in any woman with a history of peripartum hemorrhage who develops manifestations of pituitary hormone deficiency any time following the event. Appropriate hormone replacement therapy results in marked clinical improvement. We present an unusual case of SS in a young lady who continued to have normal menstruation after the index event, had two spontaneous pregnancies, and was diagnosed only 11 years later when she presented to us with acute heart failure.

Lay health educators within primary care practices to improve cancer screening uptake for South Asian patients: challenges in quality improvement

BACKGROUND

Cancer screening uptake is known to be low among South Asian residents of Ontario. The objective of this pilot study was to determine if lay health educators embedded within the practices of primary care providers could improve willingness to screen and cancer screening uptake for South Asian patients taking a quality improvement approach.

MATERIALS AND METHODS

Participating physicians selected quality improvement initiatives to use within their offices that they felt could increase willingness to screen and cancer screening uptake. They implemented initiatives, adapting as necessary, for six months.

RESULTS

Four primary care physicians participated in the study. All approximated that at least 60% of their patients were of South Asian ethnicity. All physicians chose to work with a preexisting lay health educator program geared toward South Asians. Health ambassadors spoke to patients in the office and telephoned patients. For all physicians, ~60% of South Asian patients who were overdue for cancer screening and who spoke directly to health ambassadors stated they were willing to be screened. One physician was able to track actual screening among contacted patients and found that screening uptake was relatively high: from 29.2% (colorectal cancer) to 44.6% (breast cancer) of patients came in for screening within six months of the first phone calls. Although physicians viewed the health ambassadors positively, they found the study to be time intensive and resource intensive, especially as this work was additional to usual clinical duties.

DISCUSSION

Using South Asian lay health educators embedded within primary care practices to telephone patients in their own languages showed promise in this study to increase awareness about willingness to screen and cancer screening uptake, but it was also time intensive and resource intensive with numerous challenges. Future quality improvement efforts should further develop the phone call invitation process, as well as explore how to provide infrastructure for lay health educator training and time.

Stability and durability studies of TiO2 coated immobilized system for the degradation of imidacloprid

The present article demonstrates the use of supported TiO₂ for studying the degradation of an insecticide, imidacloprid (IMI), along with durability studies of the catalyst.

An Increase Incidence in Uric Acid Nephrolithiasis: Changing Patterns

INTRODUCTION

Nephrolithiasis is a complex disease affecting all age groups globally. As the causative factors for nephrolithiasis rises significantly, its incidence, prevalence and recurrence continues to baffle clinicians and patients.

AIM

To study the prevalence of different types of renal stones extracted by Percutaneous Nephrolithotomy (PCNL) and open surgical procedures.

MATERIALS AND METHODS

Renal stones from 50 patients were retrieved by Percutaneous Nephrolithotomy (PCNL), Ureterorenoscopy (URS) and open surgical techniques for qualitative tests for detection of calcium, oxalate, uric acid, phosphate, ammonium ion, carbonate, cystine and xanthine.

RESULTS

Three patients had stone removed by open surgery and rest had undergone PCNL. Nine of the stones were pure of calcium oxalate, 9 were of pure uric acid and 32 were mixed stones. Forty one stones had calcium. Among the mixed stones, oxalate was present in 25 samples (39 of total), uric acid was seen in 17 (25 of total stones), phosphate was present in 23 (23 of total) and carbonate was present in 4 stones (4 of total). Only 1 patient had triple phosphate stone. 12 were of staghorn appearance of which 6 were of struvite type, 6 were pure uric acid and remaining were mixed oxalate-phosphate stones.

CONCLUSION

Our study, though in a small number of hospital based patients, found much higher prevalence of uric acid stones and mixed stones than reported by previous hospital based studies in north India (oxalate stones~90%, uric acid~1% and mixed stones~3%). Biochemical analysis of renal stones is warranted in all cases.

Trends of hospitalization for bulimia nervosa in USA: A nationwide analysis

Objectives

Bulimia Nervosa (BN) is an important cause of morbidity and mortality in hospitalized patients. While BN has been extensively studied in the past, the contemporary data for impact of BN on cost of hospitalization are largely lacking.

Methods

We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (HCUP-NIS) dataset between 1998-2011 using the ICD-9 codes. Severity of co-morbid conditions was defined by Deyo modification of Charlson co-morbidity index. Primary outcome was in-hospital mortality and secondary outcome was total charges for hospitalization. Using SAS 9.2, chi-square test, t-test and Cochran-Armitage test were used to test significance.

Results

19,441 patients were analyzed. 94.13% were female and 5.87% male (P < 0.0001). 85.72% were white, 4.55% black and 9.73% of other race (P < 0.0001). Rate of hospitalization decreased from 1136.99/million to 802.47/million from 1998-2011. Overall mortality was 0.20% and mean cost of hospitalization was 15,496.82$. The in-hospital mortality reduced from 0.23% to 0.15% (P < 0.0001) and mean cost of hospitalization increased from 8,194.53$ to 22,547.86$. Total spending on BN related admissions have increased from $73.96 million/year to $139.93 million/year over the last decade.

Conclusions

While mortality has slightly decreased from 1998 to 2011, the cost has significantly increased from $73.96 million/year to $139.93 million/year, which leads to an estimated $65.97 million/year additional burden to US health care system. In the era of cost conscious care, preventing BN related Hospitalization could save billions of dollars every year. Focused efforts are needed to establish preventive measures for BN related hospitalization.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Exploring the Diagnosis and Management of Bouveret's Syndrome

Bouveret's syndrome is an unusual cause of gastric outlet obstruction secondary to gallstone impaction. It is so rare that it is commonly missed in clinical practice if it is not considered in differential diagnoses of intestinal obstruction more specifically in man who does not report the history of gall stone. Furthermore, there are no definitive guidelines on approach and management of this condition. We present a seventy eight year old man who developed acute abdominal symptoms due to impaction of a gallstone in the duodenum. He did not have history of gall stone. The diagnosis was supported via CT abdomen and Endoscopy. The patient was successfully managed by exploratory laparotomy followed by anterior pylorotomy to remove the stone without cholecystectomy and fistula repair.

Pancreatic Abscess: An Unusual Presentation of Pancreatic Tail Cancer

Pancreatic abscess usually occurs in the setting of pancreatitis especially if complicated by pseudocysts or pancreatic necrosis. On the other hand, pancreatic body and tail cancer is relatively uncommon cancer and rarely does it present as a pancreatic abscess. We describe a 50-year-old man with sepsis due to underlying pancreatic abscess, who was later diagnosed to have pancreatic tail adenocarcinoma with the help of endoscopic ultrasound guided fine needle aspiration cytology.

Evaluation of cord blood ischemia modified albumin in normal pregnancies and pre-eclampsia

OBJECTIVE

Pre-eclampsia is associated with ischemia and increased oxidative stress, which may lead to modification of plasma albumin to ischemia modified albumin (IMA).

METHODS

IMA levels were estimated in cord blood of 30 newborns born to pre-eclamptic mothers and compared with 30 normal newborns. IMA was estimated colorimetrically and the results were compared statistically.

RESULTS

The levels of IMA were found to be significantly higher (p < 0.001) in newborns born to pre-eclamptic mothers (0.835 ± 0.02 ABSU) as compared to those born to normal mothers (0.325 ± 0.01 ABSU).

CONCLUSION

IMA may act as a marker of ischemia and oxidative stress in newborns delivered to pre-eclamptic mothers.

Effect of imatinib on male reproductive hormones in BCR-ABL positive CML patients: A preliminary report

Multiple animal studies, few clinical case reports and one study have observed decreased testosterone production and gynaecomastia as adverse effect of imatinib therapy. We have prospectively studied testosterone, LH and FSH levels at baseline and at 6 months of imatinib treatment in 34 newly diagnosed male BCR-ABL positive CML patients. While none of the patients had gynaecomastia at 6 months, the proportion of patients with low testosterone level increased significantly from 11.8% at baseline to 58.8% (p < 0.001) and those with high LH and FSH increased significantly from 26.4% and 23.5% to 82.4% and 76.4%, respectively (p < 0.001 and p < 0.001). Serum testosterone levels decreased significantly (p = 0.002) and serum LH and FSH levels increased significantly at 6 months of imatinib therapy (p = 0.001 and p = 0.003) in comparison to baseline levels. The findings document the effect of imatinib on testosterone levels in adult CML patients much before than reported earlier.

A convenient way to do valgus osteotomy for neglected fracture neck of femur

BACKGROUND

Neglected fracture of neck of femur in young adults is a major problem in developing countries. Existing treatment options varies from osteotomy to various graft techniques (muscle pedicle, vascularized and nonvascularized fibula etc.). There is paucity of literature regarding the use of double angle barrel plate and hip screw in such cases. We conducted a prospective longitudinal observational study with displaced, neglected fracture neck of femur in young adults and compared the results with literature.

OBJECTIVES

The aim of this study was to determine feasibility and effectiveness of 120° double angle barrel plate and hip screw fixation in neglected fracture neck of femur. Effectiveness of fixed 30 degree closed wedge osteotomy in neglected fracture neck of femur.

METHODS

Thirty cases of neglected (more than three weeks) femoral neck fracture (Pauwel II and III) of age 20-60 years were included in the study conducted at Postgraduate Institute Of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India in year 2004-06. Average age of the patient was 35.4 years (range, 22yrs-55yrs). In all cases internal fixation was done by 120° double angle barrel plate and hip Screw. At the end of follow-up, results were evaluated according to Askin Bryan Criteria and Harris-hip score.

RESULTS

Union was achieved in 28 of 30 patients. Two patients that went into nonunion were later treated with hemireplacement arthroplasty. According to Askin Bryan Criteria at the end of study, 35% patients had excellent results, 50% patients had good results. Minimum follow-up in our study was 12 months and maximum was five years.

CONCLUSION

This study validates the use of double angled screw plate configuration for successful outcome in patients with neglected fracture neck of femur. Valgus osteotomy is also technically easy operation in hands of average trauma surgeon with the use of a fixed angle plate and hip screw.

Status of leptin in MBCR-ABL p210 positive chronic myeloid leukemia patients before and after imatinib therapy: a conflicting scenario

BACKGROUND

Chronic myelogenous leukemia (CML), a myeoloproliferative disorder, is characterized by the presence of the fusion gene BCR-ABL in hematopoietic cells. Leptin, considered a link between cancer and obesity, has been reported to be actively involved in hemopoiesis and pathophysiology of CML. There are few and conflicting reports about the status of serum leptin levels and recently alteration in leptin has been reported due to imatinib mesylate.

METHODS

Leptin and CRP were estimated in 30 (male: 20; female: 10) newly diagnosed and confirmed MBCR- ABL p210 positive CML patients before and after 3 months of therapy by commercial enzyme linked immunosorbent assays. Leptin levels were compared with 30 (male: 20; female: 10) age matched healthy controls accounting for the differences due BMI and gender.

RESULTS

Leptin/BMI ratio was significantly raised in both male and female chronic phase patients as compared to controls (p < 0.001, p = 0.048) and accelerated phase patients as compared to controls (males, p < 0.001; females, p < 0.001). The normal gender difference and dependence on BMI was lost in patients. In patients, who failed to achieve hematological baseline, leptin/BMI was higher only in male patients (p = 0.012). Leptin/BMI also correlat- ed with TLC and blast percentage (TLC, R2 = 0.412, p = 0.001; Blast %, R2 = 0.408, p < 0.001). There was no correlation between leptin and CRP levels. Levels decreased significantly after complete hematological remission in both males and females (p = 0.001, p = 0.028). Levels after 3 months of imatinib therapy were significantly higher than controls in all patients not in remission (males, p < 0.001; females, p = 0.018) but only in male patients in re- mission (p = 0.002).

CONCLUSIONS

Leptin levels were increased in CML patients. The findings suggest a possible role of leptin in patho- genesis of CML or disease progression independent of inflammatory state or reactionary rise. Imatinib itself may increase leptin levels, and, as leptin plays an active role in the pathophysiology of CML, this conflicting scenario needs further investigation. Alterations in leptin need to be investigated cautiously accounting for confounding and differences due to BMI and gender.

Evaluation of maxillofacial injury in the central part of Nepal

An evaluation of dental and maxillofacial trauma in College of Medical Sciences, Teaching Hospital, Bharatpur, Nepal was carried out to assess the causes of trauma and the relationship between the injuries to the Patient's Age, Gender, Type, Site of injury and the Influence of Alcohol from June 1, 2008 to May 31, 2011. Files of 1986 trauma patients were reviewed. Maxillofacial or dental injuries were observed in 269 (13.54%) of the trauma patients, caused by road traffic accidents 173 (64.3%), fall injury 43 (16.0%), physical assault 25 (9.3%), animal attack 9 (3.3%) and sport injury 19 (7.1%) Men were hospitalized almost three times more than women, most common site of injury was dentoalveolar fracture 79(29.37%) young people were at greater risk. The most frequent age of trauma was 15-29 years (51.7%). DOI: http://dx.doi.org/10.3126/jcmsn.v7i3.6702 Journal of College of Medical Sciences-Nepal, 2011, Vol-7, No-3, 11-16  

A study on clinical attachment loss and gingival inflammation as etiologic factors in pathologic tooth migration

BACKGROUND

Several etiologic factors have been listed for pathologic migration of periodontally involved teeth based mainly on clinical observations with scarce scientific evidence. Present study was carried out to find out relationship of clinical attachment loss and gingival inflammation with pathologic tooth migration.

MATERIALS AND METHODS

A total of 37 patients having 50 pairs of migrated and non-migrated contralateral teeth were taken into consideration.

RESULTS

Mean total attachment loss per tooth in migrated and non migrated tooth is 13.32 ± 0.74 S.E. and 8.34 ± 0.58 S.E., respectively (P < 0.001), which reveals a positive correlation. There seems to be an association between frequency of migration and severity of attachment loss since highest percentage of migrations were seen in maximum total attachment loss group. Relationship could not be established between severity of attachment loss and severity of migration for which more data may be required. Also, it was seen that gingival index was significantly higher in migrated group.

CONCLUSION

Findings suggest that there exists a direct relationship between pathologic migration and clinical attachment loss as well as gingival inflammation.

CLINICAL RELEVANCE

Results emphasize the importance of early treatment of periodontitis to curb inflammation, which seems to be more important since it is completely reversible, and attachment loss also in order to prevent unaesthetic complications. Moreover bleeding along with recent change in position of teeth should be considered as important sign of active, moderate to severe periodontal disease by general dentists and hygienists so that they can refer for specialist consultation.

In vivo radioprotection studies of 3,3'-diselenodipropionic acid, a selenocystine derivative

3,3'-Diselenodipropionic acid (DSePA), a diselenide and a derivative of selenocystine, was evaluated for in vivo radioprotective effects in Swiss albino mice, at an intraperitoneal dose of 2 mg/kg body wt, for 5 days before whole-body exposure to gamma-radiation. The radioprotective efficacy was evaluated by assessing protection of the hepatic tissue, the spleen, and the gastrointestinal (GI) tract and survival against sub- and supralethal doses of gamma-radiation. DSePA inhibited radiation-induced hepatic lipid peroxidation, protein carbonylation, loss of hepatic function, and damage to the hepatic architecture. DSePA also attenuated the depletion of endogenous antioxidants such as glutathione, glutathione peroxidase, superoxide dismutase, and catalase in the livers of irradiated mice. DSePA also restored the radiation-induced reduction in villus height, crypt cell numbers, and spleen cellularity, indicating protective effects on the GI tract and the hematopoietic system. The results from single-cell gel electrophoresis of the peripheral blood leukocytes showed that DSePA can attenuate radiation-induced DNA damage. The mRNA expression analysis of genes revealed that DSePA augmented GADD45alpha and inhibited p21 in both spleen and liver tissues. DSePA also inhibited radiation-induced apoptosis in the spleen and reversed radiation-induced alterations in the expression of the proapoptotic BAX and the antiapoptotic Bcl-2 genes. In line with these observations, DSePA improved the 30-day survival of irradiated mice by 35.3%. In conclusion, these findings clearly confirm that DSePA exhibits protective effects against whole-body gamma-radiation and the probable mechanisms of action involve the maintenance of antioxidant enzymes, prophylactic action through the attenuation of the DNA damage, and inhibition of apoptosis.

Treatment of neglected elbow dislocations with combination of speed V-Y muscleplasty and intra-articular injection of hydrocorticosone

Neglected dislocations of the elbow are not uncommon in developing countries. We report case series of 3 cases of neglected dislocations of elbow. All the three cases were treated by combination of Speeds procedure and intraarticular injection of 25mg of hydrocorticosone acetate in 5 ml of distilled water. Mean time from injury was 5 months and mean follow-up was 10 months. According to Mayo Elbow Performance Index, 2 outcomes were excellent and 1 outcome was good.