Metabolic dysfunction associated steatotic liver disease: Current practice, screening guidelines and management in the primary care setting

Metabolic dysfunction associated steatotic liver disease, previously known as non-alcoholic fatty liver disease, is the most common cause of chronic liver disease in the United States with rapidly rising prevalence. There have been significant changes recently in the field with screening now recommended for patients at risk for significant liver fibrosis in primary care and endocrine settings, along with clear guidance for management of metabolic comorbidities and changes in nomenclature. This paper serves as a summary of recent guidance for the primary care physician focusing on identifying appropriate patients for screening, selecting suitable screening modalities, and determining when referral to specialty care is necessary. The hope is that providers will shift away from past practices of utilizing liver tests alone as a screening tool and shift towards fibrosis screening in patients at risk for significant fibrosis. This culture change will allow for earlier identification of patients at risk for end stage liver disease and serious liver related complications, and overall improved patient care.

Nasopharyngeal Carriage of Streptococcus pneumoniae Serotypes Among Healthy Children in Northern India

Streptococcus pneumoniae (SP) infections cause morbidity and mortality among children worldwide. Hence India introduced 13-valent pneumococcal conjugate vaccine (PCV-13) in 2017 in a phased manner. The primary objective of this study was to assess the proportion of healthy children having nasopharyngeal colonization (NP) with SP. Secondary objective was to determine prevalent serotype of SP among the PCV13 vaccinated and non-vaccinated children. This cross-sectional study was conducted in 4 hospitals of Lucknow District, Northern India. Three hundred healthy children (2-59 months) were recruited between July and August 2019 from vaccination-clinics of hospitals. NP specimen was cultured using 5% sheep blood agar plate containing gentamicin. Pneumococcal isolates were identified by optochin sensitivity and bile-solubility tests. Serotyping was done using Quellung Method. Of the 300 healthy children, 56.7% (170/300) were males and 59.3% (181/300) had received at least one dose of PCV13 vaccine. The NP carriage rate of SP among healthy children was 37.7% (113/300). Vaccine serotypes were found in 33.3% (22/66) in PCV vaccinated children and 48.9% (23/47) in non-vaccinated children (p 0.09). Common vaccine serotypes that isolated were: 18C, 19A, 19F, 23F, 3, 4, 6A, 6B, 9 V. Thus more than one-third of healthy children had NP colonization with SP. Adjusting for age, there was a trend for significant reduction in vaccine serotypes in the NP with one doses versus two or more doses (ptrend = 0.04).

Survival outcomes of patients with relapsed or refractory acute myeloid leukemia after venetoclax combined with hypomethylating agents

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Background: Venetoclax in combination with hypomethylating agents (HMA+Ven) is the standard-of-care treatment for patients with newly diagnosed acute myeloid leukemia (AML) who are ineligible for intensive chemotherapy. HMA+Ven is also commonly used as salvage therapy for relapsed or refractory (R/R) AML. There is limited data regarding outcomes of AML patients after HMA+Ven failure. In clinical practice, survival following HMA+Ven failure, either as frontline or salvage therapy, is observed to be poor. Methods: We conducted a single center retrospective study to evaluate survival outcomes of AML patients who were R/R to HMA+Ven as frontline or salvage therapy. Patients ≥ 18 years of age with AML who initiated HMA+Ven between 06/2018 and 05/2021 were included. R/R AML was defined as clinically relevant disease with ≥ 5% blasts after prior complete remission/morphologic leukemia free state, refractoriness to at least two cycles of HMA+Ven, or progressive disease despite initiating HMA+Ven. Data cut-off was 02/07/2022. Overall survival (OS) was estimated using Kaplan-Meier method and outcome differences between sub-groups were assessed using the log rank test. Results: Forty-two patients met inclusion criteria. Baseline characteristics and treatment details are summarized in Table. The median OS of the overall cohort was 2.3 months (range 0.1-11.4). There was no significant difference in median OS between patients declared R/R to frontline vs salvage HMA+Ven (2.4 vs 1.8 months, hazard ratio [HR] = 0.84, 95% confidence interval [CI] 0.43-1.62). Patients who received treatment after HMA+Ven failure had longer median OS compared to patients who did not (n = 17, 4.7 vs 1.7 months, HR = 0.29, 95% CI 0.13-0.62). There was no significant difference in OS based on the sub-type of AML, ELN risk group, p53 mutation, or complex karyotype status. Conclusions: Data from our study support the clinical observation that AML patients with disease R/R to HMA+Ven, either as frontline or salvage therapy, have very poor survival outcomes. These results provide important prognostic information for clinicians and highlight the need for novel therapies for R/R AML.[Table: see text]

COVID-19 in Patients With Rheumatic Diseases: Is There a Need to Worry?

BACKGROUND/OBJECTIVES

SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), first described in December 2019, has infected more than 33 million people and claimed more than 1 million deaths worldwide. Rheumatic diseases are chronic inflammatory diseases, the prevalence and impact of which in COVID-19 patients are poorly known. We performed a pooled analysis of published data intending to summarize clinical presentation and patient outcomes in those with established rheumatic disease diagnosis and concurrent COVID-19.

METHODS

PubMed and Google Scholar were searched to identify studies reporting data about rheumatic disease patients who were diagnosed with SARS-CoV-2 infection and published until July 22, 2020. Random-effects models were used to estimate the pooled incidence and rates of hospitalization, intensive care unit admission, and mortality among these patients, and interstudy heterogeneity was identified using I2 statistics with greater than 75% value indicating substantial interstudy variation.

RESULTS

Twenty studies were included, giving a total sample size of 49,099 patients positive for SARS-CoV-2. Of 49,099 COVID-19 patients, a total of 1382 were also diagnosed with a rheumatic disease in the past. The random-effects pooled prevalence of COVID-19 among rheumatic disease patients was found to be 0.9%. The rates of hospitalization, intensive care unit admission, and mortality were 70.7%, 11.6%, and 10.2%, respectively.

CONCLUSIONS

Although the prevalence of SARS-CoV-2 infection is not dramatically high in rheumatic disease patients, concurrent COVID-19 does seem to play a role in determining disease severity and outcomes to some extent. Further studies are needed to give conclusive evidence about whether this subset of the population is at a higher risk of COVID-19 and related outcomes compared with the population at large.

Ligand Interactions and Nanoparticle Shapes Guide the Pathways toward Interfacial Self-Assembly

Non-equilibrium molecular dynamics simulations are used to probe the driving forces behind the formation of highly ordered, epitaxially connected superlattices of polyhedral-shaped nanoparticles (NPs) at fluid-fluid interfaces. By explicitly modeling coarse-grained ligands that cap the NP surface, it is shown that differences in NP shapes and time-dependent facet-specific ligand densities give rise to drastically different transformation mechanisms. Our results indicate that the extent of screening of the inter-particle interactions by the surrounding solvation environment has a significant impact on reversibility and ultimately the coherence of the final two-dimensional superlattice obtained. For the particle shapes examined, a hexagonal pre-assembly and a square superlattice final assembly (upon preferential ligand desorption from {100} facets) were prevalent; however, cuboctahedral NPs formed intermediate epitaxially bonded branched clusters, which eventually grew and rearranged into a square lattice; in contrast, truncated octahedral NPs exhibited an abrupt rhombic-to-square transition driven by the clustering of their numerous {111}-ligands that favored the stacking of linear NP rods. To track the incipient order in the system, we also outline a set of novel order parameters that measure the local orientation alignment between nearest-neighbor pairs. The simulation protocols advanced in this work could pave the way forward for exploration of the vast phase space associated with the interfacial self-assembly of NPs.

COVID-19 and Tuberculosis: A Meeting of Two Pandemics!

Coronavirus disease 2019 (COVID-19), causes serious respiratory illness manifesting as pneumonia, adult respiratory distress syndrome and respiratory failure. Amidst the rising number of cases and deaths, it is imperative to not forget Tuberculosis (TB) which is another pandemic existing since centuries. There could be dire consequences for tuberculosis patients globally especially in low and middle income countries with a high burden of disease and overwhelmed health care systems. Tuberculosis is still the leading infectious killer worldwide, and therefore, it is crucial to reflect on the interaction between the two diseases. Evidence suggests that both COVID-19 and tuberculosis have a synergistic relationship, boosting detrimental effect of each other, disrupting existing health care models, and also worsening the clinical outcomes in terms of morbidity and mortality. This review aims to draw attention towards this pertinent clinical issue, and tries to unravel the intricate relationship between COVID-19 and tuberculosis, as also the role of BCG vaccination to combat the COVID-19 pandemic.

Admission Hyperglycemia in Non-diabetics Predicts Mortality and Disease Severity in COVID-19: a Pooled Analysis and Meta-summary of Literature

In the latter part of 2019, a cluster of unexplained pneumonia cases were reported in Wuhan, China. In less than a year, SARS-CoV-2 has infected over 27 million people and claimed more than 800,000 deaths worldwide. Diabetes is a highly prevalent chronic metabolic disease, and recent reports have suggested a possible existence of COVID-19 related new-onset diabetes. Hyperglycemia induces an inflammatory state in the body, which coupled with coronavirus associated immune response is a possible explanation for clinical worsening of patients. We present a summary and pooled analysis of available evidence to ascertain the relationship between hyperglycemia in undiagnosed diabetics and outcomes of COVID-19 disease. Our results showed that hyperglycemia in non-diabetics was associated with higher risk of severe/critical illness (OR 1.837 (95% CI 1.368–2.465, P < 0.001) and mortality (2.822, 95% CI 1.587–5.019, P < 0.001) compared with those with normal values of blood glucose. The management of hyperglycemia in COVID-19 poses significant challenges in clinical practice, and the need to develop strategies for optimal glucose control in these patients cannot be overlooked.

An Implicit-Solvent Model for the Interfacial Configuration of Colloidal Nanoparticles and Application to the Self-Assembly of Truncated Cubes

This study outlines the development of an implicit-solvent model that reproduces the behavior of colloidal nanoparticles at a fluid-fluid interface. The center point of this formulation is the generalized quaternion-based orientational constraint (QOCO) method. The model captures three major energetic characteristics that define the nanoparticle configuration-position (orthogonal to the interfacial plane), orientation, and inter-nanoparticle interaction. The framework encodes physically relevant parameters that provide an intuitive means to simulate a broad spectrum of interfacial conditions. Results show that for a wide range of shapes, our model is able to replicate the behavior of an isolated nanoparticle at an explicit fluid-fluid interface, both qualitatively and often nearly quantitatively. Furthermore, the family of truncated cubes is used as a test bed to analyze the effect of changes in the degree of truncation on the potential-of-mean-force landscape. Finally, our results for the self-assembly of an array of cuboctahedra provide corroboration to the experimentally observed honeycomb and square lattices.

Complex regional pain syndrome—A forgotten entity

Complex Regional Pain Syndrome (CRPS) is a painful condition characterized by regional pain that is disproportionate temporality and severity to the usual course of any known cause. The pain is regional which is not in a specific nerve territory or dermatomal distribution. Judicious clinical suspicion and targeted investigations are necessary for correct diagnosis and appropriate treatment. We hereby report a case of a young lady with CRPS who presented to us with unilateral upper limb pain, swelling, discoloration and muscle atrophy without any history of inciting injury.

Nanocomposites of C3N4 with Layers of MoS2 and Nitrogenated RGO, Obtained by Covalent Cross-Linking: Synthesis, Characterization, and HER Activity

Generation of hydrogen by photochemical, electrochemical, and other means is a vital area of research today, and a variety of materials have been explored as catalysts for this purpose. C₃N₄, MoS₂, and nitrogenated RGO (NRGO) are some of the important catalytic materials investigated for the hydrogen evolution reaction (HER) reaction, but the observed catalytic activities are somewhat marginal. Prompted by preliminary reports that covalent cross-linking of 2D materials to generate heteroassemblies or nanocomposites may have beneficial effect on the catalytic activity, we have synthesized nanocomposites wherein C₃N₄ is covalently bonded to MoS₂ or NRGO nanosheets. The photochemical HER activity of the C₃N₄-MoS₂ nanocomposite is found to be remarkable with an activity of 12778 μmol h^-1 g^-1 and a turnover frequency of 2.35 h^-1. The physical mixture of C₃N₄ and MoS₂, on the other hand, does not exhibit notable catalytic activity. Encouraged by this result, we have studied electrochemical HER activity of these composites as well. C₃N₄-MoS₂ shows superior activity relative to a physical mixture of MoS₂ and C₃N₄. Density functional theory calculations have been carried out to understand the HER activity of the nanocomposites. Charge-transfer between the components and greater planarity of cross-linked layers are important causes of the superior catalytic activity of the nanocomposites. Covalent linking of such 2D materials appears to be a worthwhile strategy for catalysis and other applications.

Patents on Endophytic Fungi

BACKGROUND

Endophytic fungi are taxonomically and ecologically heterogeneous group of organisms, mainly belonging to the Ascomycotina and Deuteromycotina. Endophytes usually produce the enzymes necessary for the colonization of plant tissues. Endophytes are able to utilize components of plant cells without disturbing host metabolism, which is confirmed by isozyme analysis and studies on substrate utilization. The patents related to enzymes and metabolites produced by endophytic fungi are associated with their ecological significance. Application of metabolites and growth promoting factors produced from endophytic fungi, in the pharmaceutical and agricultural industries, is now well established. The patents on secretion of extracellular enzymes in vitro by endophytic fungi needed for cell wall degradation, support the hypothesis that fungal endophytes represent a group of organisms specialized to live within plant tissue.

OBJECTIVE

This review presents the patents granted on different aspects of endophytic fungi for the last 11 years. This expresses the scenario and impact of these patents regarding significance in human society.

CONCLUSION

In the last few years, research and inventions regarding the different aspects of endophytic fungi beneficial for host plant as well as for human beings have been carried out, which is supported by the increasing number of patents granted on endophytic fungi.

Persistent Trophoblastic Disease at Cesarean Scar

Pregnancy over the cesarean scar is the rarest cause of ectopic pregnancy and development of persistent trophoblastic disease at the scar site is extremely rare. A high index of suspicion is needed for early diagnosis and management of cesarean scar molar pregnancy. This condition is difficult to diagnose and must be considered in the patient with a history of cesarean section who has persistent vaginal bleeding or symptoms of pregnancy after suction evacuation. Diagnosis can be confirmedby measuring ß Human Chorionic Gonadotropin levels, transvaginal ultrasound with doppler flow evaluation. As this is an uncommon condition, this case report with conservative non surgical approach will add up to its clinical spectrum.

Prediction equations for spirometry in adults from northern India

BACKGROUND

Most of the Indian studies on prediction equations for spirometry in adults are several decades old and may have lost their utility as these were carried out with equipment and standardisation protocols that have since changed. Their validity is further questionable as the lung health of the population is likely to have changed over time.

OBJECTIVE

To develop prediction equations for spirometry in adults of north Indian origin using the 2005 American Thoracic Society/European Respiratory Society (ATS/ERS) recommendations on standardisation.

METHODS

Normal healthy non-smoker subjects, both males and females, aged 18 years and above underwent spirometry using a non-heated Fleisch Pneumotach spirometer calibrated daily. The dataset was randomly divided into training (70%) and test (30%) sets and the former was used to develop the equations. These were validated on the test data set. Prediction equations were developed separately for males and females for forced vital capacity (FVC), forced expiratory volume in first second (FEV1), FEV1/FVC ratio, and instantaneous expiratory flow rates using multiple linear regression procedure with different transformations of dependent and/or independent variables to achieve the best-fitting models for the data. The equations were compared with the previous ones developed in the same population in the 1960s.

RESULTS

In all, 685 (489 males, 196 females) subjects performed spirometry that was technically acceptable and repeatable. All the spirometry parameters were significantly higher among males except the FEV1/FVC ratio that was significantly higher in females. Overall, age had a negative relationship with the spirometry parameters while height was positively correlated with each, except for the FEV1/FVC ratio that was related only to age. Weight was included in the models for FVC, forced expiratory flow (FEF75) and FEV1/FVC ratio in males, but its contribution was very small. Standard errors of estimate were provided to enable calculation of the lower limits of normal and standardised residuals for these parameters. The equations were found to be valid on the test dataset, and therefore, may be extended to general population. Comparison with the 1960s equations revealed lack of good agreement, and substantially higher predicted FVC with the current equations, especially in the forty-years-plus age group, in both males and females. Even in the age group upto 40 years, the level of agreement was clinically not acceptable.

CONCLUSIONS

Validated prediction equations have been developed for spirometry variables in adults of north Indian origin using the current ATS/ERS spirometry standardisation recommendations. The equations suggest an improvement in the lung health of the population over time in the middle-aged and the elderly. These equations should address a long-felt unmet need and enable a more appropriate evaluation of spirometry data in different chest diseases in Indian subjects.

A rare case of hemolytic anemia in a pediatric patient due to ring dehiscence after mitral valve repair: utility of real-time three-dimensional imaging and management

A rare case of hemolytic anemia in a 3-year-old child due to mitral valve ring dehiscence is described. The dehiscence of mitral valve ring was diagnosed utilizing real-time three-dimensional echocardiography. The patient subsequently underwent reoperation with successful resolution of hemolysis after replacement of the ring.

Chronic infections & coronary artery disease with special reference to Chalmydia pneumoniae

BACKGROUND & OBJECTIVES

Studies on cardiovascular diseases (CVD) in India have shown about 10-20 per cent of cases with no obvious risk factors, raising a suspicion of infections as a cause. There is a paucity of data on this possible role of infections. This study was, therefore, undertaken to find out the association between infection due to Chlamydia pneumoniae and other organisms and coronary artery disease (CAD).

METHODS

Patients with CAD were selected in group I (acute myocardial infarction, AMI) and group III (patients undergoing coronary artery bypass graft (CABG) surgery), and normal controls in group II. Routine biochemical, haematological and inflammatory tests [C-reactive protein (CRP), total leucocyte count (TLC), fibrinogen, ESR], serodiagnostic tests for IgA and IgG antibodies to C. pneumoniae, Helicobacter pylori, cytomegalovirus (CMV), Mycoplasma pneumoniae and Parvovirus B-19 by ELISA kits, C. pneumoniae antigen by microimmunofluorescence and PCR from endothelial tissue obtained at CABG were carried out. Aortic punch biopsies were done in patients who underwent CABG.

RESULTS

Acute MI patients had a significantly higher association with accepted cardiac risk factors, lipid profile, inflammatory and thrombogenic tests. IgG and IgA antibodies levels against C. pneumoniae were not significantly different in the controls as against the AMI group. However, C. pneumoniae antigen seropositive group had significant association with HDL cholesterol, lipid tetrad index (P<0.001) and with triglycerides. Parvovirus B antigen was detected in 8.3 per cent of tissue specimens by PCR and of 44 patients with AMI (6.8%) were also positive for parvovirus B-19 IgG antibodies.

INTERPRETATION & CONCLUSIONS

There was no direct evidence of the involvement of C. pneumoniae and other infective agents and viruses in CAD. It is possible that such infections produce an indirect adverse effect on the lipid profile.

Influence of different generations of poly(propylene imine) dendrimers on human erythrocytes

The unique characteristics of dendrimers make them attractive candidates as drug carriers. However, the toxicity associated with dendrimers is a basic hurdle in their biomedical application. To ensure development of dendrimer based safe and effective delivery systems, the effect of dendrimers on human erythrocytes (RBCs) must be studied. The present study explores the toxicological behavior of different generations of poly(propylene imine) dendrimers on human RBCs. Plain fifth generation PPI dendrimers (1 mg/mL) showed approximately 6.39% hemolysis which was an indication of their suitability in drug delivery. The study was conducted on all generations from 0.5 to 5.0 G of PPI dendrimers.

Biowaiver: an alternative to in vivo pharmacokinetic bioequivalence studies

Bioequivalence is a vital concern in drug development even more significant in the case of Narrow Therapeutic Index (NTI) drugs. In clinical development of New Chemical Entities (NCE), bioequivalence studies necessitate to be performed when the formulation of the pharmaceutical dosage form has been changed. In vivo pharmacokinetic data can be used as surrogate parameters for in vivo solubility and permeability data. The Biopharmaceutics Classification System (BCS) has emerged as a helpful tool in product development by alluding to the in vivo performance of the active substance. The bio-relevance of the BCS properties and the in vitro release are best expressed through a correlation between in vitro and in vivo data. Recently BCS has been implemented for waiving bioequivalence studies on the basis of the solubility and gastrointestinal permeability of drug substance and can be strategically deployed to save time and resources during generic drug development. The BCS has been adopted as a very useful tool for in vivo drug design and development worldwide, particularly in terms of regulatory standards. A BCS-based biowaiver has become an important and cost-saving tool in approval of generic drugs.

Topical phenytoin suspension and normal saline in the treatment of leprosy trophic ulcers: a randomized, double‐blind, comparative study

OBJECTIVE

To evaluate and compare two strengths of topical phenytoin sodium suspension (2% and 4%) with normal saline in the healing of acute trophic ulcers in leprosy patients.

METHODS

A prospective, parallel, double-blind, randomized study was conducted in 45 leprosy inpatients with acute trophic ulcers. Patients were randomized to receive 2%, 4% or normal saline dressing on their ulcers once daily for 4 weeks. Efficacy parameters such as a reduction in the surface area of the ulcer, bacterial culture of the ulcer swab, appearance of healthy granulation tissue, cessation of ulcer discharge and overall gradation of clinical healing and safety were assessed at weekly intervals.

RESULTS

The ulcer area reduction was greater in the 2% and 4% phenytoin groups compared with the normal saline group (p<0.001). Appearance of healthy granulation tissue and cessation of ulcer discharge was also observed earlier in the two phenytoin groups. At the end of 4 weeks, 11 ulcers each had healed completely in both the 2% and 4% phenytoin groups compared with none in the control group. There were no statistical differences between the 2% and 4% phenytoin groups. No side effects were reported by any patient.

CONCLUSION

Topical phenytoin appears to be an effective, safe and cheap therapeutic option for the healing of trophic ulcers in leprosy patients.

Impact of glitazones on metabolic and haemodynamic parameters in patients with type 2 diabetes mellitus

INTRODUCTION

Diabetes mellitus is a common disorder associated with a number of metabolic abnormalities such as insulin resistance, dyslipidaemia and high blood pressure. These abnormalities are recognised risk factors for cardiovascular diseases. Insulin-sensitising drugs exert an effect on these cardiovascular risk factors. The present study was done with the objective of elucidating the differences in glycaemic control, plasma lipid levels and blood pressure in diabetic patients who were prescribed glitazones in combination with sulphonylureas.

METHODS

Patients were randomly assigned to receive either pioglitazone or rosiglitazone in addition to glimepiride in an open-labelled study. Fasting and postprandial blood glucose levels, glycosylated haemoglobin, fasting lipid profile and blood pressure were recorded at baseline and at various intervals until the end of the study period at 12 weeks.

RESULTS

A total of 56 patients (28 in the pioglitazone group and 28 in the rosiglitazone group) completed the study. There was no significant difference in the baseline values of various parameters between the two treatment groups. The efficacy of the two treatment groups was similar in terms of the maintenance of blood glucose levels (fasting blood glucose, p-value is 0.10; postprandial blood glucose, p-value is 0.95; glycosylated haemoglobin, p-value is 0.30) and the effect on blood pressure (systolic blood pressure, p-value is 0.45; diastolic blood pressure, p-value is 0.95), while the pioglitazone group showed significantly better efficacy in improving the lipid profile compared to the rosiglitazone group (total cholesterol, p-value is 0.002; triglycerides, p-value is 0.002; low density lipoprotein, p-value is 0.005; and high density lipoprotein, p-value is 0.43).

CONCLUSION

The two drugs showed a similar effect on blood glucose levels and blood pressure. However, the pioglitazone group was superior to the rosiglitazone group in improving the lipid profile.

Tyrosinaemia type II with diffuse plantar keratoderma and self-mutilation

Tyrosinaemia type II (oculocutaneous tyrosinaemia or Richner-Hanhart syndrome) is a rare and potentially treatable genetic disorder. Corneal opacities or ulcers, circumscribed palmoplantar keratoderma and subnormal intelligence form the classical triad of this syndrome. A case with additional features of self-harm and diffuse plantar keratoderma is discussed. Emphasis is laid on the importance of early diagnosis and intervention in the form of dietary regulation to prevent the neurological signs and treat the oculocutaneous symptoms.

Quality medicines for the poor: experience of the Delhi programme on rational use of drugs

Prior to 1994, most Delhi hospitals and dispensaries experienced constant shortages of essential medicines. There was erratic prescribing of expensive branded products, frequent complaints about poor drug quality and low patient satisfaction. Delhi took the lead in developing a comprehensive Drug Policy in 1994 and was the only Indian state to have such a comprehensive policy. The policy's main objective is to improve the availability and accessibility of quality essential drugs for all those in need. The Delhi Society for the Promotion of Rational Use of Drugs (DSPRUD), a non-governmental organization, worked in close collaboration with the Delhi Government and with universities to implement various components of the policy. The first Essential Drugs List (EDL) was developed, a centralized pooled procurement system was set up and activities promoting rational use of drugs were initiated. In 1997, the Delhi Programme was designated the INDIA-WHO Essential Drugs Programme by the World Health Organization. The EDL was developed by a committee consisting of a multidisciplinary group of experts using balanced criteria of efficacy, safety, suitability and cost. The first list contained 250 drugs for hospitals and 100 drugs for dispensaries; the list is revised every 2 years. The pooled procurement system, including the rigorous selection of suppliers with a minimum annual threshold turnover and the introduction of Good Manufacturing Practice inspections, resulted in the supply of good quality drugs and in holding down the procurement costs of many drugs. Bulk purchasing of carefully selected essential drugs was estimated to save nearly 30% of the annual drugs bill for the Government of Delhi, savings which were mobilized for procuring more drugs, which in turn improved availability of drugs (more than 80%) at health facilities. Further, training programmes for prescribers led to a positive change in prescribing behaviour, with more than 80% of prescriptions being from the EDL and patients receiving 70-95% of the drugs prescribed. These changes were achieved by changing managerial systems with minimal additional expenditure. The 'Delhi Model' has clearly demonstrated that such a programme can be introduced and implemented and can lead to a better use and availability of medicines.

Necrotic erythema nodosum leprosum

A 30 year-old farmer presented himself with mild degree fever, joint pain and multiple ulcers of 15 days' duration. Ulcers were multiple, well-defined, irregular in shape with necrotic base and elevated, sloppy margins over anus, forearms, wrists, buttocks, lower half of thighs and shins. A few of the ulcers were covered with black-coloured scab. They were tender and with serosanguinous discharge. Black atrophic scars and ill-defined, irregular, brown black-pigmented macules of various sizes were present over thighs and legs. Excision biopsy of the ulcer showed features of erythema nodosum leprosum. The patient was treated with systemic corticosteroids.

Sub-polar lepromatous leprosy presenting as urticarial wheals: a case report

A 40-year male lepromatous leprosy patient presented with four, slightly erythematous patches, with multiple urticaria-like wheals, distributed over the body symmetrically and with thickened right ulnar and right common peroneal nerves. He was previously diagnosed as a case of chronic idiopathic urticaria. Slit skin smear from the patches and urticarial wheals showed a BI of 3+ and skin biopsy showed some features of borderline lepromatous leprosy (BL).

Embryo/fetal toxicity assessment of lasofoxifene, a selective estrogen receptor modulator (SERM), in rats and rabbits

BACKGROUND

The purpose of this study was to evaluate the effects of lasofoxifene, a selective estrogen receptor modulator (SERM), on rat and rabbit fetal development.

METHODS

Lasofoxifene was administered orally to rats (1, 10, 100 mg/kg) between gestation days (GD) 6-17, and in rabbits (0.1, 1, 3 mg/kg) between GD 6-18. Maternal body weight and food consumption were monitored throughout pregnancy. Fetuses were delivered by Cesarean section on GD 21 in rats, and GD 28 in rabbits, to evaluate fetal viability, weight, and morphology. Drug concentrations in maternal plasma were measured in a separate cohort of animals at several time points commencing on GD 17 (rats) and 18 (rabbits). On GD 18 (rat) and GD 19 (rabbit) drug concentrations were measured in maternal plasma and in fetal tissue 2 hr post dosing to determine the fetal to maternal drug ratio.

RESULTS

In rats, there were dose-related declines in maternal weight gain and food consumption. Post implantation loss was significantly increased at dosages of 10 and 100 mg/kg, and the number of viable fetuses was decreased at 100 mg/kg. The placental weights increased, whereas fetal weights decreased in a dose-dependent manner. Lasofoxifene-related teratologic findings were noted at 10 and 100 mg/kg and included imperforate anus with hypoplastic tails, dilatation of the ureters and renal pelvis, misaligned sternebrae, hypoflexion of hindpaw, wavy ribs, and absent ossification of sternebrae. In rabbits, neither maternal weight gain nor food consumption were affected during treatment. Between GD 26-28, there was a dose-dependent increased incidence of red discharge beneath the cages. At 1 and 3 mg/kg, resorptions and post-implantation loss increased. There were no significant external or visceral effects, but 3 mg/kg there was an increased incidence of supernumerary ribs. Although the maternal plasma Cmax and AUC(0-24) were dose-dependent, the exposures in the rat were many orders of magnitude greater than in the rabbit even for the same 1 mg/kg dose. The single time point fetal/maternal drug ratio was higher in the rat (1.3-0.78) than in the rabbit (0.21-0.16).

CONCLUSION

In general, both maternal and fetal effects of lasofoxifene were similar to those reported with other SERMs. Although the incidence or severity of these effects was, in some instances, greater in the rat than in the rabbit, the doses and the resultant maternal and fetal exposures were many orders of magnitude higher in the rat, suggesting the rabbit to be more sensitive to the toxicological effects of lasofoxifene.

Reproductive toxicity assessment of lasofoxifene, a selective estrogen receptor modulator (SERM), in female rats

BACKGROUND

Lasofoxifene is a nonsteroidal selective estrogen receptor modulator (SERM). With high affinity to the alpha and beta human estrogen receptors and greater potency than other SERMs, lasofoxifene is potentially a superior treatment for postmenopausal osteoporosis. In light of the known effects of estrogen-modulating compounds on female reproductive indices, two studies were conducted to evaluate the effects of lasofoxifene on female rat cyclicity, reproduction, and parturition.

METHODS

One study evaluated effects of lasofoxifene on estrous cyclicity, and the second study assessed effects on implantation and parturition. In the cyclicity study, lasofoxifene was administered to female rats at doses of 0.1, 0.3, and 1.0 mg/kg/day for 14 consecutive days. After treatment, there was a 3-week reversibility phase followed by a mating phase. In the implantation study, lasofoxifene was administered to pregnant female rats at doses of 0.01, 0.03, and 0.1 mg/kg/day for 7 consecutive days (gestation day [GD] 0-6). Some animals were euthanized on GD 21, and the remainder of the group was allowed to deliver the F1 generation. Several developmental indices were evaluated in the F1 pups through post-natal day (PND) 21.

RESULTS

In the cyclicity study, all lasofoxifene-treated females were anestrous by Study Day 7 (1.0 mg/kg) or 9 (0.3 and 0.1 mg/kg). The reversibility phase resulted in restoration of normal estrous cycles by the end of 1 (0.1 mg/kg) or 2 weeks (0.3 and 1.0 mg/kg). During the mating phase, no adverse effects occurred in pregnancy success or reproductive parameters. In the implantation study, all doses of lasofoxifene increased pre- and post-implantation losses, increased gestation length, and reduced litter size. None of the developmental parameters measured on the F1 generation was adversely affected.

CONCLUSION

Lasofoxifene reversibly altered the estrous cycle and inhibited implantation, consistent with what would be expected from a member of the SERM class.

Comparison of the developmental toxicity of aspirin in rabbits when administered throughout organogenesis or during sensitive windows of development

BACKGROUND

A review of the nonsteroidal anti-inflammatory drug (NSAID) literature suggested occurrences of low-level incidences of cardiovascular and midline defects in rabbit fetuses exposed in utero. Aspirin (acetylsalicylic acid, ASA) is a widely used NSAID that irreversibly inhibits cyclooxygenases (COXs) 1 and 2. ASA has been studied extensively in rats and has consistently increased low-incidence cardiovascular malformations and defects in midline closure. The objectives of the current study were to comprehensively define the developmental toxicology profile of ASA in rabbits by using a dosing paradigm encompassing the period of organogenesis and to test the hypothesis that maternal gastrointestinal toxicity after repeated dose administrations hampers the detection of low-incidence malformations with ASA in rabbits by limiting ASA administration to sensitive windows for cardiovascular development and midline closure.

METHODS

ASA was administered to pregnant New Zealand White rabbits from gestation days (GDs) 7 to 19 at dose levels of 125, 250, and 350 mg/kg per day and as single doses of 500, 750, or 1000 mg/kg on GD 9, 10, or 11. Cesarean sections were performed on GD 29, and the fetuses were examined for external, visceral and skeletal development.

RESULTS

In the repeated dose study, maternal toxicity was exhibited in the 250- and 350-mg/kg per day groups by mortality and decreased food consumption and body weight gain. In the single dose studies, maternal toxicity was exhibited at all doses by reductions in body weight gain and food consumption for 3 days after treatment. Fetal body weight was significantly reduced in the repeated dose study at 350 mg/kg per day. Fetal weights were not affected by single doses of ASA on GD 9, 10, or 11. There were no treatment-related external, visceral or skeletal malformations associated with ASA administration throughout organogenesis or with single doses administered during critical developmental windows.

CONCLUSION

These findings supported previous work demonstrating that ASA is not teratogenic in rabbits, as opposed to rats, even when large doses are administered on single days during specific windows of development.

Oral ivermectin in scabies patients: a comparison with 1% topical lindane lotion

Scabies. which constitutes a significant proportion of the outpatient attendance in tropical dermatology clinics, has so far been treated with lindane, crotamiton, sulphur, permethrin, etc. Ivermectin, an orally administered drug, was tried in scabies patients and compared with 1% topical lindane lotion to evaluate its effects and toxicity profile. Two hundred scabies patients were randomly allocated to one of two groups. One group received oral invermectin in a single dose of 200 micrograms/kg body weight. The other received 1% lindane lotion for topical application overnight. Patients were assessed after 48 hours, two weeks and four weeks. After a period of four weeks, 82.6% of the patients in the ivermectin group showed marked improvement; only 44.44% of the patients in the lindance group showed a similar response. A side effects in the form of severe headache were noted in one patient in group A. Oral ivermectin is an easy drug to administer. It is given as a single oral dose, unlike lindane, which has to be applied topically. The compliance is accordingly increased. Moreover, ivermectin induces an early and effective improvement in signs and symptoms. Thus, it may be a better option for scabies than the traditional topical linlane lotion.

Efficacy of nimesulide alone and in combination with cetirizine in acute allergic rhinitis

OBJECTIVE

To study the effect of cetirizine and nimesulide given alone and in combination in allergic rhinitis.

METHOD

A double blind, double dummy, randomised, parallel controlled clinical study in three groups consisting of 18 patients each suffering from allergic rhinitis was conducted. Group A was given nimesulide alone (100 mg BD), Group B received combination (nimesulide 100 mg + cetirizine 10 mg) and Group C was given cetirizine alone (10 mg) for one week. The efficacy of each treatment in reducing nasal stuffiness, nasal discharge, itching nose and watery eyes was assessed at base line (day 0), on days four and eight of treatment. Patients used diary cards twice daily to rate symptom severity on a four point scale.

RESULTS

Nimesulide and cetirizine alone could decrease nasal discharge, nasal stuffiness and sneezing significantly in allergic rhinitis patients by day four. Cetirizine was more effective in relieving nasal discharge and sneezing compared to nimesulide. By combining cetirizine and nimesulide four symptoms of allergic rhinitis, i.e., nasal discharge, nasal stuffiness, sneezing and watery eyes decreased significantly.

CONCLUSION

Present study has shown that nimesulide alone could decrease three symptoms of allergic rhinitis like certirizine and combination of cetirizine (anti-histaminic) and nimesulide (anti-inflammatory) exerts synergistic action in reducing symptoms in patients of allergic rhinitis.

Pseudoexstrophy in a female child

A six-year-old female patient presenting with a swelling in the infraumbilical part of the abdomen, bulging out on straining, was diagnosed to have pseudoexstrophy bladder. The urinary tract was normal. The patient had bifid clitoris. There was no other associated malformation. Surgical repair of abdominal wall defect was done successfully. A new classification of exstrophy variants is proposed.