Preoperative vaginal cleansing with chlorhexidine and cetrimide solution for reduction of postoperative infectious morbidity at a tertiary care center in North India: A prospective cohort study

OBJECTIVE

To determine the effect of preoperative vaginal cleansing with chlorhexidine and cetrimide solution on postoperative infectious morbidity.

METHODS

This prospective cohort study was conducted over a period of 18 months in the Department of Obstetrics and Gynecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India. Women undergoing cesarean section were alternately allotted to study and control groups. Women with chorioamnionitis, antepartum hemorrhage, rupture of membranes for more than 24 h, and fever in the preoperative period were excluded. The study group received preoperative vaginal cleansing with antiseptic solution (7.5% chlorhexidine w/v and 15% cetrimide w/v); the control group did not receive vaginal cleansing. Both groups were followed for the presence of any infectious morbidity until they were discharged from the hospital.

RESULTS

Age, body mass index (calculated as weight in kilograms divided by the square of height in meters), gestational age, and the parity of the women in the study and control groups were comparable (n = 760). The rate of endometritis was lower in the study group, but the difference was not statistically significant (P = 0.054). Post-cesarean febrile morbidity and wound sepsis were significantly lower in the study group (P = 0.017 and P = 0.02, respectively). On subgroup analysis, women in the study group with rupture of the membranes before cesarean delivery had lower wound sepsis and a reduced duration of hospital stay. Women in the study group with emergency cesarean delivery showed a significant reduction in wound sepsis, febrile morbidity, and length of hospital stay.

CONCLUSION

Preoperative vaginal cleansing with chlorhexidine and cetrimide solution before a cesarean section reduces postoperative infectious morbidity.

Carle's obstetric early warning score as a screening tool for critical care admission

BACKGROUND OBJECTIVES

Early warning systems (EWS) involve serial observations (track) with criteria (trigger) to timely identify patients at risk of complications. Carle designed a statistically based clinically modified obstetric early warning score (Carle's OEWS). This study evaluated Carle's OEWS and its individual components for predicting admission to the obstetric critical care unit (OCCU). Maternal near-miss and maternal mortality were the secondary outcomes.

METHODS

A prospective observational study was conducted among 1250 pregnant women with a period of gestation ≥28 week admitted in the labour wards of a tertiary centre over 18 months. The physiological parameters of OEWS were recorded and aggregate score was calculated at admission and at regular intervals thereafter, till discharge or OCCU admission.

RESULTS

The area under receiver operating characteristic (ROC) curve of OEWS was 0.975 for predicting OCCU admission, 0.971 for near-miss, and 0.996 for predicting maternal mortality and was significant for all outcomes. All individual parameters, except diastolic blood pressure, had a significant relative risk for predicting OCCU requirement.

INTERPRETATION CONCLUSIONS

Carle's OEWS is a useful screening tool for predicting obstetric OCCU admission and can be routinely used in labour wards to ensure timely intervention.

Intrauterine instillation of autologous platelet-rich plasma in infertile females with thin endometrium undergoing intrauterine insemination: an open-label randomized controlled trial

BACKGROUND

Thin endometrium in infertile female patients has always been a clinical challenge for the treating reproductive physicians.

OBJECTIVE

This study aimed to evaluate the effect of intrauterine instillation of autologous platelet-rich plasma on endometrial thickness and vascularity in infertile female patients with thin endometrium undergoing ovarian stimulation with intrauterine insemination.

STUDY DESIGN

This prospective randomized control study included 120 women undergoing ovarian stimulation with intrauterine insemination, aged between 21 and 37 years, with persistent thin endometrium (<7 mm) on ≥1 cycle in previous ovarian stimulation cycles, even after conventional treatment with estradiol valerate. The women were randomly assigned to study group A and control group B. Baseline endometrial thickness and endometrial vascularity were noted. Intrauterine instillation of autologous platelet-rich plasma was done on the day of trigger in group A, whereas estradiol valerate was given in group B. Another evaluation of endometrial parameters was done on the day of intrauterine insemination. The cycle was repeated for 3 cycles or until the pregnancy was achieved, whichever occurred earlier. Parameters were noted for both groups. Primary outcomes were the change in endometrial thickness and endometrial vascularity. Secondary outcomes were positive pregnancy rate and clinical pregnancy rate.

RESULTS

In group A, mean pre-platelet-rich plasma endometrial thickness was 4.66±0.79 mm, which significantly increased to 7.47±0.85 mm after platelet-rich plasma instillation (P<.05) after 3 cycles. This increase was significantly greater than that observed in group B. There was significant increase in endometrial vascularity in group A compared with group B (P<.05). The positive pregnancy rate and clinical pregnancy rate in group A were 23.73% and 18.64%, respectively, and significantly higher than those in group B.

CONCLUSION

Autologous platelet-rich plasma is a promising, easily procurable, and novel option for management of infertile females with thin endometrium not responding to conventional treatment. Using it in intrauterine insemination cycles can reduce costs and psychological burden of this subgroup of women by reducing the need for resorting to advanced options such as in vitro fertilization and surrogacy.

Effect of laser bleaching, ultrasonic scaling and powered tooth brushing on surface roughness and bacterial adherence of class V composite restorations

Objective

To evaluate and compare the effect of diode laser assisted bleaching, ultrasonic scaling and powered tooth brushing on surface roughness and bacterial adherence on class V cavities restored with composites.

Materials and methods

A total of one hundred and twenty samples (40 samples each of Brilliant Everglow, Beautifil II and Heytec-N) were prepared in standardized stainless steel molds. The samples were further subdivided into four subgroups i.e. one control group (without any intervention) and three experimental groups - diode laser assisted bleaching, ultrasonic scaling and powered tooth brushing consisting of 10 sample each. Surface roughness was measured quantitatively with the help of 3D Optical Profilometer. For bacterial adherence analysis S. mutans strain (ATCC 25175) was cultured in BHI medium and samples were evaluated for the presence of viable bacteria using the Colony Forming Unit (CFU) count. Results obtained were then tabulated and subjected to statistical analysis.

Results

Diode laser bleaching caused a significant increase in surface roughness and bacterial adherence with lowest mean change exhibited by Heytec-N followed by Beautifil II and highest by Brilliant Everglow group. Similarly, Ultrasonic scaling increased the surface roughness of all the three tested samples with significant difference between the groups. Powered tooth brushing had no effect on the surface roughness and bacterial adherence of the tested composites.

Conclusion

Diode assisted laser bleaching and ultrasonic caused significantly higher surface roughness and bacterial adherence values for all the tested composites. It may therefore be recommended to do finishing and polishing of restorations after such procedures.

Adiponectin to Leptin Ratio and its Association with Insulin Resistance in Women with Polycystic Ovarian Syndrome

BACKGROUND

Adiponectin and leptin play a major role in metabolic homeostasis. Adiponectin to Leptin ratio can be used as an indicator of insulin resistance and a marker of polycystic ovarian syndrome (PCOS). The study was planned to compare serum adiponectin, leptin, and adiponectin to leptin ratio in age and BMI matched women with and without PCOS and to find out the association of adiponectin to leptin ratio with Insulin resistance in these women.

METHODS

It was a cross-sectional study done in the Gynecology outpatient clinic in a tertiary care center. A total of 120 women, 60 with PCOS and 60 age and BMI matched women without PCOS, who presented in the clinic after the index cases were enrolled and tested for serum adiponectin, leptin, and insulin sensitivity. The main outcome measures were serum levels of adiponectin, leptin, adiponectin to leptin ratio, oral glucose tolerance test, serum insulin and HOMA-IR.

RESULTS

PCOS women had lower serum Adiponectin, higher serum Leptin level and lower Adiponectin to Leptin ratio compared to non PCOS women, 2.15 ± 3.07 ng/ml vs 10.7 ± 27.91 ng/ml, P < 0.0001; 24.25 ± 16.5 ng/ml vs 13.89 ± 11.19 ng/ml, P = 0.0003 and 0.15 ± 0.24 vs 3.03 ± 15.04, P < 0.0001, respectively. Plasma glucose 2 hours after 75 gm glucose and serum Insulin was significantly increased in PCOS women (108.78 ± 10.22 mg/dl vs 100.18 ± 4.89 mg/dl, P = 0.001 and 5.7 ± 9.53 mU/ml vs 3.02 ± 5.34 mU/ml, P = 0.02, respectively). The mean values of fasting plasma glucose and HOMA-IR were comparable in both groups, P = 0.145, P = 0.719, respectively. There was no significant association of A/L Ratio with BMI, plasma glucose 2 hours after 75 gm glucose, serum Insulin and HOMA-IR, in these women, r = -0.074, P = 0.5754; r = -0.203, P = 0.12; r = -0.018, P = 0.8915; and r = -0.041, P = 0.757, respectively.

CONCLUSION

Adiponectin to leptin ratio is significantly reduced in women with PCOS but has no association with insulin resistance.

Critical Level of Alanine Transaminase to Predict Foetomaternal Outcome in Intrahepatic Cholestasis of Pregnancy: A Case-control Study

Introduction: Intrahepatic Cholestasis of Pregnancy (IHCP) is a disorder of the second and third trimester causing pruritis without a rash in the women. To avoid the adversities, early delivery is indicated before serum bile acids levels of >40 μmol/L is reached. In the settingswhere bile acid testing is not available, serum transaminases can be used for diagnosis and management of IHCP. Aim: To find out value of Alanine Transaminase (ALT) for the prediction of adverse outcomes. Materials and Methods: This case-control study was carried out from October 2018 to March 2020, enrolled 75 singleton women with IHCP and 75 controls in their third trimester. The diagnosis was based on the presence of pruritis without an identifiable dermatological cause along with raised serum transaminases. Serum ALT levels and the foetomaternal outcomes were noted. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0. Mann-Whitney test, Chi-square test and Fisher’s exact test were used to compare all variables. The p-value of <0.05 was considered statistically significant. Results: The mean age of women in the IHCP and control groups was 24.81±4.2 and 25.95±5.13 years, respectively and the mean gestational age of women was 34±2.89 weeks. Women with IHCP had increased incidence of induction of labour (p=0.0003) and meconium staining of liquor (p=0.002) as compared to controls. Serum ALT levels showed a significant positive association with meconium staining of liquor (p=0.041), Intrauterine Death (p=0.01), and Neonatal Intensive Care Unit (NICU) admission (p=0.006) in women with IHCP. An ALT value of 133 U/L was found to be predictive of adverse foetal outcomes with sensitivity, specificity and likelihood ratio of 65.7%, 82.5% and 3.76, respectively. Conclusion: IHCP leads to adverse foetal outcomes. But pruritis is the only maternal distress. ALT >133 U/L is predictive of adverse foetal outcome, therefore, termination of pregnancy can be advocated above this level.

Obstetric Early Warning Score for Prognostication of Critically Ill Obstetric Patient

Introduction

Obstetric early warning score (OEWS) has been used conventionally for early identification of deteriorating obstetric patients in the labor room and ward settings. This study was conducted to determine if this simple clinical score could be used for prognosticating a critically ill patient in the ICU setting instead of sequential organ failure assessment score (SOFA) and acute physiology and chronic health evaluation (APACHE II) score.

Materials and Methods

A cohort study was conducted at Obstetrics Critical Care Unit, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi. A total of 250 obstetric patients were recruited after informed consent. The OEWS, SOFA, and APACHE II scores were calculated within 24 hours of admission. The patients were followed to study the maternal outcome.

Results

The area under receiver operator characteristic (AUROC) curve of OEWS, SOFA, and APACHE II for prediction of maternal mortality was 0.894 (95% CI, 0.849–0.929), 0.924 (95% CI, 0.884–0.954), and 0.93 (95% CI, 0.891–0.958), respectively. The standardized mortality ratio (SMR) for OEWS, SOFA, and APACHE II was 66.3, 62.5, and 69.15%, respectively.

Conclusion

Obstetric early warning score is as effective as the conventional SOFA and APACHE II to prognosticate the obstetric patient. Since OEWS is based only on clinical criteria, it can be done immediately on admission and can help in early allocation of appropriate manpower and resources for optimum outcome.

Clinical significance

The clinical application of this study will help intensivists to prognosticate the critically ill obstetric patients immediately following admission to the critical care unit.

How to cite this article

Khergade M, Suri J, Bharti R, Pandey D, Bachani S, Mittal P. Obstetric Early Warning Score for Prognostication of Critically Ill Obstetric Patient. Indian J Crit Care Med 2020;24(6):398–403.

Evaluation of reliability of self-collected vaginal swabs over physician-collected samples for diagnosis of bacterial vaginosis, candidiasis and trichomoniasis, in a resource-limited setting: a cross-sectional study in India

OBJECTIVES

Self-collected vaginal swabs can facilitate diagnosis of vaginal discharge (VD) in resource-limited settings, provided reliability of the method is established. The aim of this study was to evaluate the concordance between self-collected and physician-collected vaginal swabs for aetiological diagnosis of VD and to determine the prevalence of bacterial vaginosis (BV), vulvovaginal candidiasis (VVC) and trichomonas vaginitis (TV).

METHODS

A total of 550 females (median age: 32 years; range: 18-45 years) attending two sexually transmitted infection/reproductive tract infection (STI/RTI) clinics with VD from January 2015 to May 2016 were included in the study after obtaining written informed consent. Swabs were self-collected by patients after instructions and subsequently by a physician under speculum examination. Samples were processed for standard bedside tests, Gram staining, wet mount and culture (gold standard) according to the national guidelines. Concordance between the two methods was determined by the Cohen's kappa value.

RESULTS

BV, VVC and TV were diagnosed in 79 (14.4%), 144 (26.2%) and 3 (0.5%) patients, respectively. VVC coexisted with BV in 58 (10.5%) patients. There was no coinfection of TV with BV or VVC. Candida albicans was isolated in 84 (58.3%) VVC cases. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of self-collected swabs for diagnosing BV was 91.1%, 100%, 100% and 98.5%, respectively, while for the C. albicans VVC and TV, sensitivity, specificity, PPV and NPV all were 100% as compared with physician-collected swabs. Highly concordant results were obtained between two methods by the Kappa values of 0.95 (BV), 0.99 (VVC) and 1.0 (TV).

CONCLUSION

The comparative performance of self-collected and physician-collected vaginal swabs establishes self-collection of samples for BV, VVC and TV as a viable alternative tool in the management of STIs/RTIs, especially in peripheral and resource-constrained settings. This would be effective in implementing the diagnostic approaches for STIs/RTIs in community-based surveillance studies at national or regional level and therefore strengthening the National STI/RTI Control Programme.

Assessment of labor progression by intrapartum ultrasonography among term nulliparous women

OBJECTIVE

To assess cervical dilation, fetal head station, and fetal head position by intrapartum ultrasonography and to compare the approach with digital vaginal examination (DVE).

METHODS

An observational study conducted from October 2015 to January 2017 among term nulliparous women in active labor at a tertiary hospital in Delhi, India. Cervical dilation, head station, and head position were assessed by DVE, followed by ultrasonography within 10 minutes. The women's preference was also evaluated.

RESULTS

Overall, 458 observations were obtained for 215 women. Cervical dilation measured by DVE was strongly correlated with ultrasonography findings (intraclass correlation coefficient, 0.945; 95% confidence interval, 0.932-0.956; κ=0.837; P<0.001). Data for fetal head station and head position showed a fair correlation (κ=0.353 and κ=0.554, respectively; both P<0.001). The majority of women (186/215, 87%) reported a preference for ultrasonography over DVE for assessment of labor progression in a future pregnancy.

CONCLUSION

Intrapartum ultrasonography was preferred as an objective assessment tool for labor progression among term nulliparous women and therefore should be practiced in all labor rooms. Further studies on interobserver variation are recommended to establish the reproducibility of intrapartum assessment by ultrasonography.

Comparison of placenta accreta spectrum disorders diagnosed in intrapartum and antepartum period- A three year experience in a tertiary referral unit of India

OBJECTIVE

To determine the frequency of placenta accreta spectrum (PAS) disorders and to study the demographic profile, risk factors and maternal and fetal outcomes in women with antepartum diagnosis of PAS as compared to women with diagnosis made in the intrapartum period.

STUDY DESIGN

Retrospective analysis over a 3-year period of all patients who delivered with PAS. The cases were divided into 2 groups. Group 1 consisted of the patients who were diagnosed during the intra partum period and Group 2 was those diagnosed as PAS by ultrasound in the antepartum period. Maternal and fetal outcomes were compared between the 2 groups. The cases that underwent conservative management were also analyzed for need of secondary hysterectomy/placental resolution RESULTS: There were 81,480 deliveries conducted during the study period of which 74 were identified as PAS. Hence PAS was seen in 1:1101 deliveries (0.09%). The estimated blood loss and number of units of blood products required were significantly higher in Group 1 (2.36 ± 0.77 l vs 1.8 ± 0.91 L, p = 0.002; and 10.17 ± 5.12 vs 6.77 ± 4.22, p = 0.005) compared to Group 2. The ICU stay was also more common in Group 1 (p = 0.01). The perinatal mortality was significantly higher in Group 1(45.71% vs 23.08%, p = 0.040). 79.7% women underwent primary cesarean hysterectomy while others were managed conservatively. In conservatively managed group, placental resolution took place in 60% and 40% required secondary hysterectomy.

CONCLUSION

Antenatal diagnosis of placenta accreta spectrum disorders decreases the maternal morbidity and perinatal mortality.

Retained Intra-uterine Foetal Bones Resulting in Secondary Infertility: A Case Report

Termination of pregnancy (abortion) is a reasonably safe procedure when properly performed. However, even after being performed with due precautions, complications may occur. Retention of fetal products following a mid-trimester abortion is a rare complication of abortion which can then result in secondary infertility. We are here presenting the case of a young woman who underwent an abortion in the 15th week of gestation due to anencephaly in the fetus and who then failed to conceive for the next five years. Transvaginal ultrasonographic examination suggested the presence of bone-like structures in the uterine cavity which were removed hysteroscopically. The patient was able to conceive after the hysteroscopic removal of bony fragments. Retained bony fragments from a previous mid-trimester abortion should thus be kept in the list of differentials of secondary infertility.

Term Live Secondary Abdominal Pregnancy: A Case Report

Term, live abdominal pregnancy secondary to rupture of a uterine rudimentary horn is a rare condition. Pregnancies conceived in the rudimentary horn of the uterus usually rupture during early gestation and present as a catastrophic event. However, rarely, after rupture of the uterine horn the foetus may continue to grow in the abdominal cavity and reach term gestation. A primigravida with a term pregnancy was referred to our centre for caesarean section with ultrasonography findings of transverse lie and placenta previa. During surgery, a live baby was extracted from the abdominal cavity, revealing a bicornuate uterus with rupture of the rudimentary horn. The early peroperative diagnosis and prompt control of the bleeding with excision of the rudimentary horn and transfusion of multiple blood products saved the patient's life. The case is presented for its rarity and to highlight the importance of a high index of suspicion in cases presenting with abnormal foetal presentation.

Non-visualisation of strings after postplacental insertion of Copper-T 380A intrauterine device

Aim

To assess the incidence of visible strings of intrauterine contraceptive devices (IUDs) after postplacental insertion following vaginal or caesarean delivery and to establish a management protocol of follow-up visits when strings are not visualised.

Methods

This was a prospective study of a cohort of 348 women who underwent postplacental insertion of Copper-T 380A IUDs following vaginal or caesarean delivery, conducted at a hospital in New Delhi, India. Women were followed up at 6 weeks, 3, 6 and 12 months after IUD insertion and were questioned about IUD expulsion or removal at each visit. The cervix was inspected to visualise the IUD strings. All women whose IUD strings could not be visualised at the cervical os at any given follow-up were identified. We analysed the cumulative incidence of visible strings and of procedures performed to locate the IUD when strings were not visible.

Results

At 1 year follow-up, the IUD wasin situin 313/348 (89.9%) women. There were eight (2.3%) expulsions and 15 (4.3%) IUD removals. Among women with IUDsin situ, the strings were not visible in 73 (21%) cases. Pelvic ultrasound confirmed intrauterine position of the IUDs in these cases. At 1 year, string visibility was significantly lower after intra-caesarean insertions as compared to vaginal insertions (72.4% vs 98.1%;p<0.05).

Conclusions

Visualisation of strings after postplacental vaginal insertion is more common than after intra-caesarean insertion. Pelvic ultrasonography can be used to verify the presence of the device in cases of missing strings.

Tailor-Made Temperature-Sensitive Micelle for Targeted and On-Demand Release of Anticancer Drugs

The design of nanomedicines from the tuned architecture polymer is a leading object of immense research in recent years. Here, smart thermoresponsive micelles were prepared from novel architecture four-arm star block copolymers, namely, pentaerythritol polycaprolactone-b-poly(N-isopropylacrylamide) and pentaerythritol polycaprolactone-b-poly(N-vinylcaprolactam). The polymers were synthesized and tagged with folic acid (FA) to render them as efficient cancer cell targeting cargos. FA-conjugated block copolymers were self-assembled to a nearly spherical (ranging from 15 to 170 nm) polymeric micelle (FA-PM) with a sufficiently lower range of critical micelle concentration (0.59 × 10(-2) to 1.52 × 10(-2) mg/mL) suitable for performing as an efficient drug carrier. The blocks show lower critical solution temperature (LCST) ranging from 30 to 39 °C with high DOX-loading content (24.3%, w/w) as compared to that reported for a linear polymer in the contemporary literature. The temperature-induced reduction in size (57%) of the FA-PM enables a high rate of DOX release (78.57% after 24 h) at a temperature above LCST. The DOX release rate has also been tuned by on-demand administration of temperature. The in vitro biocompatibilities of the blank and DOX-loaded FA-PMs have been studied by the MTT assay. The cellular uptake study proves selective internalization of the FA-PM into cancerous cells (C6 glioma) compared that into normal cells (HaCaT). In vivo administration of the DOX-loaded FA-PMs into the C6 glioma rat tumor model resulted in significant accumulation in tumor sites, which drastically inhibited the tumor volume by ∼83.9% with respect to control without any significant systemic toxicity.

GW627368X inhibits proliferation and induces apoptosis in cervical cancer by interfering with EP4/EGFR interactive signaling

PGE2, the major product of cyclooxygenases implicated in carcinogenesis, is significantly upregulated in cervical cancer. PGE2 via prostanoid receptor EP4 stimulates proliferation and motility while inhibiting apoptosis and immune surveillance. It promotes angiogenesis by stimulating the production of pro-angiogenic factors. The present study demonstrates GW627368X, a highly selective competitive EP4 antagonist, which hinders cervical cancer progression by inhibiting EP4/epithelial growth factor receptor (EGFR) interactive signaling. GW627368X reduced protein kinase A (PKA) phosphorylation which in turn leads to decreased cAMP response element-binding protein (CREB) activation. Decreased PKA phosphorylation also directly enhanced Bax activity and in part reduced glycogen synthase kinase 3 (GSK3)β phosphorylation. Owing to the interactive signaling between EP4 and EGFR, GW627368X lowered EGFR phosphorylation in turn reducing Akt, mitogen-activated protein kinase (MAPK) and GSK3β activity significantly. Sublethal dose of GW627368X was found to reduce the nuclear translocation of β-catenin in a time dependent manner along with time-dependent decrease in cytoplasmic as well as whole-cell β-catenin. Decreased CREB and β-catenin transcriptional activity restricts the aberrant transcription of key genes like EP4, cyclooxygenase (COX)-2, vascular endothelial growth factor and c-myc, which ultimately control cell survival, proliferation and angiogenesis. Reduced activity of EGFR resulted in enhanced expression of 15-hydroxyprostaglandin dehydrogenase increasing PGE2 degradation thereby blocking a positive feedback loop. In xenograft model, dose-dependent decrease in cancer proliferation was observed characterized by reduction in tumor mass and volume and a marked decrease in Ki67 expression. A diminished CD31 specific staining signified decreased tumor angiogenesis. Reduced expression of pAkt, pMAPK, pEGFR and COX-2 validated in vitro results. GW627368X therefore effectively inhibits tumor survival, motility, proliferation and angiogenesis by blocking EP4/EGFR interactive signaling. EP4 is a potent therapeutic target in cervical cancer and can be explored in combination with conventional therapies to attain superior outcomes and to overcome complications associated with organ toxicities, therapeutic resistance and disease relapse.

Diacerein-mediated inhibition of IL-6/IL-6R signaling induces apoptotic effects on breast cancer

Interleukin-6 (IL-6) signaling network has been implicated in oncogenic transformations making it attractive target for the discovery of novel cancer therapeutics. In this study, potent antiproliferative and apoptotic effect of diacerein were observed against breast cancer. In vitro apoptosis was induced by this drug in breast cancer cells as verified by increased sub-G1 population, LIVE/DEAD assay, cell cytotoxicity and presence of terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL)-positive cells, as well as downregulation of antiapoptotic proteins Bcl-2 and Bcl-xL and upregulation of apoptotic protein Bax. In addition, apoptosis induction was found to be caspase dependent. Further molecular investigations indicated that diacerein instigated apoptosis was associated with inhibition of IL-6/IL-6R autocrine signaling axis. Suppression of STAT3, MAPK and Akt pathways were also observed as a consequence of diacerein-mediated upstream inhibition of IL-6/IL-6R. Fluorescence study and western blot analysis revealed cytosolic accumulation of STAT3 in diacerein-treated cells. The docking study showed diacerein/IL-6R interaction that was further validated by competitive binding assay and isothermal titration calorimetry. Most interestingly, it was found that diacerein considerably suppressed tumor growth in MDA-MB-231 xenograft model. The in vivo antitumor effect was correlated with decreased proliferation (Ki-67), increased apoptosis (TUNEL) and inhibition of IL-6/IL-6R-mediated STAT3, MAPK and Akt pathway in tumor remnants. Taken together, diacerein offered a novel blueprint for cancer therapy by hampering IL-6/IL-6R/STAT3/MAPK/Akt network.

Supplementation of vitamin D in pregnancy and its correlation with feto-maternal outcome

CONTEXT

Vitamin D deficiency is widely prevalent throughout the world. Pregnant women, neonates and infants form most vulnerable groups for vitamin D deficiency.

OBJECTIVE

(1) To find prevalence of vitamin D deficiency in pregnant women. (2) To evaluate the effect of supplementation with cholecalciferol in improving vitamin D levels in pregnant women and evaluate its correlation with feto-maternal outcome.

DESIGN

Randomized control trial from years 2010 to 2012.

SETTING

Tertiary care centre, Delhi, India.

PARTICIPANTS

One-hundred and eighty pregnant women. Study population divided randomly into two groups: group A: nonintervention (60 women) and group B: intervention (120 women).

INTERVENTION

The intervention group received supplementation of vitamin D in dosages depending upon 25(OH)-D levels.

MAIN OUTCOME MEASURES

Risk of maternal complications such as preterm labour, pre-eclampsia and gestational diabetes associated with vitamin D deficiency and risk of low birthweight and poor Apgar score in infants of mothers with vitamin D deficiency.

RESULTS

Adjusted serum 25(OH)-D concentration was lower in group A as compared to group B (mean 46·11 ± 74·21 nmol/l vs 80 ± 51·53 nmol/l). Forty-four percent patients in group A and 20·3% patients in group B developed preterm labour/pre-eclampsia/gestational diabetes. Newborns of mothers in group A had lower cord blood levels of 25(OH)-D levels as compared to group B (mean 43·11 ± 81·32 nmol/l vs 56·8 ± 47·52 nmol/l). They also had lower birthweight of mean 2·4 ± 0·38 kg as compared to group B 2·6 ± 0·33 kg.

CONCLUSIONS

Vitamin D supplementation reduces risk of maternal comorbidities and helps improve neonatal outcomes.

Feto-maternal Outcome Using New Screening Criteria of Serum TSH for Diagnosing Hypothyroidism in Pregnancy

INTRODUCTION

Evidence suggests that by using the classical non pregnant reference range for serum TSH (STSH), one might miss hypothyroidism in pregnancy. Therefore, upper normal cut off value of S TSH should be taken as <2.5 mIU/L in the first trimester and <3mIU/L in the second and third trimester. However, two Indian studies have reported higher trimester specific reference ranges in the Indian pregnant women.

OBJECTIVES

To assess the maternal and fetal outcomes using new screening criteria with upper S TSH cut off as >3mIU/L, for diagnosing hypothyroidism in pregnancy.

MATERIALS AND METHODS

This study was a cross sectional study, carried out in the Department of Obstetrics and Gynaecology of a tertiary care hospital, in collaboration with the Department of Endocrinology. Pregnant women with ≤ 20 weeks gestation, attending antenatal OPD from December 2010 to January 2012 were included in the study. On the basis of S TSH level, women were divided into Study Group with S TSH level between 3.1 to 6.2 mIU/L, (new range to be studied) and an equal number of age and parity matched Control Group with S TSH levels between 0.4 to 3 mIU/L. The maternal and fetal outcomes were compared between study and control groups.

RESULTS

During the study period, a total of 66 women had S TSH between 3.1-6.2 mIU/L. Maternal and fetal outcomes in both the groups were comparable. There was no difference in the mode of delivery between study and control groups.

CONCLUSION

The lower S TSH cut off recommended for diagnosing hypothyroidism in pregnancy may not be applicable to pregnant Indian women.

To evaluate the effect of perceived stress on menstrual function

INTRODUCTION

Menstrual irregularities affect 2-5% of childbearing women, a number that is considerably higher among females under constant stress during a cycle.

AIM

To study the effect of perceived stress on cycle length, regularity and dysmenorrhoea.

MATERIALS AND METHODS

A cross-sectional study was conducted on 100 female undergraduate students of a medical college. A questionnaire along with the Perceived Stress Scale (PSS) and Pictorial Blood Assessment Chart (PBAC) was provided to the students. The menstrual pattern was then correlated with the PSS using the chi- square test and the Fisher's Exact test for statistical analysis.

OBSERVATIONS AND RESULTS

Out of the 100 undergraduate medical students, 30 students had a PSS score >20 while 70 had a score ≤20. An association was established between high stress levels (PSS >20) and menstrual irregularity. No association was found in students with PSS >20 with hypomenorrhoea, menorrhagia, dysmenorrhoea, long cycle length and short cycle length.

CONCLUSION

High stress levels (PSS >20) was associated with only menstrual irregularities and not with duration, amount of flow or dysmenorrhoea. Hence, other causes should be looked for in young women complaining of menstrual problems before stress is assumed to be the cause.

Clinical Outcome of Postplacental Copper T 380A Insertion in Women Delivering by Caesarean Section

INTRODUCTION

Short interconception period after caesarean section and its associated risk of increased morbidity, mortality and surgical interventions could be avoided by postplacental IUCD insertion during the procedure. Despite the safety reports on intracaesarean IUCD insertion, obstetricians are still hesitant to extend the benefit of this long acting reversible contraception to women undergoing operative delivery.

OBJECTIVE

To study the clinical outcome (safety, efficacy, expulsion and continuation rates) of postplacental Copper T 380A insertion in primiparous women undergoing caesarean section.

MATERIALS AND METHODS

This study was a prospective observational study, carried out in the Department of Obstetrics and Gynaecology, Safdarjung hospital, which is a tertiary care hospital of Northern India. Primiparous women who delivered by caesarean section over a period of six months (July 2012 to December 2012), willing for postplacental intracaesarean IUCD insertion, and willing to comply with the study protocol, were recruited for the study. All these subjects fulfilled the WHO Standard Medical Criteria for PPIUCD insertion; follow up visits were scheduled at 1, 3, 6 and 12 months.

RESULTS

A total of 300 primiparous women underwent postpartum intracaesarean insertion of Copper T 380A. The mean age of women included in the study was 23.12 ± 2.42 years. Most common postinsertion complication observed in the immediate postoperative period was febrile morbidity (2%). Majority of women (94.33%) had hospital stay of less than 4 days. The common adverse events observed during follow-up of 12 months were menstrual complaints, excessive vaginal discharge and persistent pelvic pain. At the end of one year, there were 16 expulsions, 21 removals, and 2 pregnancies with gross cumulative expulsion, removal, failure and continuation rates of 5.33%, 7%, 0.67% and 91%, respectively.

CONCLUSION

Postplacental intracaesarean Copper T 380A insertion in primiparous women is a safe and effective method of reversible contraception, with low expulsion and high continuation rates.

Risk assessment for psychological disorders in postmenopausal women

INTRODUCTION

Psychological symptoms are common & bothersome in post menopausal women. Hence, screening these women for risk factors for psychological disorders is an important measure to improve their health.

OBJECTIVE

To study the risk assessment for psychological disorders in postmenopausal women Material & Methods: This was a prospective and observational study conducted in the Department of Obstetrics and Gynecology of a North Indian tertiary care hospital. It included a cross-section of 200 postmenopausal women attending gynecology OPD and menopausal clinic.

RESULT

Psychological symptoms were present in 32% postmenopausal women while sleep disturbance and decreased concentration were reported by nearly 34%. Irritability, nervousness and depression were the presenting complaints in 31.5%, 28.5% and 23.5% women respectively. Mild depression was present in 41.5%, whereas 3% women suffered from clinical (moderate to severe) depression. Depression was significantly associated with vasomotor symptoms (p=0.000), past history of depression (p=0.048) and psychosocial stressors (p=0.000).

CONCLUSION

Women during postmenopausal years are at increased risk of psychological disorders; hence assessment of mental health and address of related issues should be an integral part of comprehensive evaluation of these women.

Leprosy among circus workers

Seven (2.31%) circus workers of two circus companies visiting Amritsar were detected to be suffering from leprosy. Whether or not they acquired the disease during their stay in circus is not so important, but it is necessary to detect and treat these itinerant persons. Our experience clearly underlines the necessity for undertaking surveys of various workers living in crowded conditions (like circus), because of their occupation.

Mesalazine in treatment of psoriasis

Mesalazine- a 5 lipoxygenase inhibitor was tried in this open trial on 20 psoriatics. Whereas 50% patients (10) had complete clearance in 4 weeks, by 12 weeks 85% (17) patients had good response and 15% (3) patients had no relief at all. No side effects were observed. Further longitudinal double-blind trials of this drug, which has an advantage of not causing bone marrow depression and oligospermia over sulfasalazine, another 5 lipoxygenase inhibitor, are advocated.

Sulfasalazine in treatment of psoriasis

A 5-lipoxygenase inhibitor-sulfasalazine was compared to a known effective drug-methotrexate in psoriasis. Fifteen patients each were put on sulfasalazine (1500 mg/day) and methotrexate (7.5 mg/week). Assessment was made on the basis of EST (Erythema, Scaling and Thickness) scale, initially and then weekly upto 4 weeks followed by 4 weekly upto 12 weeks. Efficacy was comparable for the 2 drugs: decrease in mean EST in patients on methotrexate and sulfasalazine therapy was 86.55% and 83.64% at 4 weeks; and 92.86% and 92.13% at 12 weeks respectively. Nine patients on sulfasalazine therapy and 10 patients on methotrexate therapy had complete clearance at the end of 12 weeks.

Relapse, reinfection or inadequate MDT ?

Relapse by all standard definitions is reported in a middle aged woman after PB MDT. Since she belonged to a family of treated leprosy sufferers (husband and his elder brother) and her daughter has now developed infectious type of leprosy, the possibility of reinfection can also not be ruled out.

Incontinentia pigmenti

A case of incontinentia pigmenti, a rare genodermatosis, is being presented.

Chromoblastomycosis

This is an account of twenty eight years of sufferings of a young sikh agriculturist, who ultimately succumbed to chromoblastomycosis- a not so uncommon mycotic infection, despite the use of toxic (amphoterecin-B) and newer antimycotic drugs (ketoconazole). Involvement of face, small and large gut, larynx and trachea are the other highlights of this case.

Pefloxacin in leprosy

Fluoroquinolones, a new class of compounds characterised by broad antimicrobial spectrum including mycobacteria together with limited toxicity, have recently been introduced in the chemotherapy of various human infectious diseases. Pefloxacin, one of the members of this class, was recently demonstrated to be bactericidal against M.leprae in the mouse foot-pad model and clinically beneficial in lepromatous leprosy patients. Clinical response to standard MDT with added pefloxacin in ten previously untreated (both PB and MB) was compared with that in ten similar patients on MDT alone in the present trial. The results of chemotherapy were quantified by a method of clinical scoring. This pilot study showed that addition of pefloxacin led to significant and rapid clinical improvement. There were no side effects attributable to pefloxacin.

Improving NLEP performance in a low endemic area

New innovative strategies of the medical officer of an upgraded urban leprosy centre of a low endemic state (Punjab) resulted in an increase in new case detection by seventy-four percent. Indigenous patients were much more regular than immigrant patients in colonies. The number of new indigenous punjabi patients has not shown any decline in last one decade, probably because of deficiencies in the functioning of NLEP. It is suggested that improved case detection by adopting strategies used by the authors and restricting free migration of untreated and partially treated patients would help in achieving the goals of NLEP.