Prevalence and Predictors of Depression, Anxiety and Stress among Elderly during COVID-19: A Cross-sectional Study from Central India

During the COVID-19 pandemic, elderly people have been more prone to depression, anxiety and stress. During these trying times, they require more attention and support for their mental health. This cross-sectional study was performed with the duration of 06 months from March 2021 to August 2021 in AIIMS, Bhopal in the state of Madhya Pradesh, in central India. And the participants recruited by systematic random sampling from a population aged more than 60 years, those who were able to read and write Hindi or English and having at least one family member; who reported to AIIMS, Bhopal during the second wave of COVID-19 in India. Those who were confirmed COVID-19 cases and undergoing treatment for the same, with diagnosed mental health disorders and who didn't give consent were excluded. A Google form based online semi-structured questionnaire along with DASS-21 scale was completed by participants. Elderly (>=60 years) will be selected. Of the 690 participants 7.25% reported mild to moderate depression, whereas 0.58 percent had severe or extremely severe depression. Mild to moderate anxiety were found in 9.56% of people, while 2.46% had severe or extremely severe anxiety. Mildly or moderately were stressed 4.78%, while 0.42% was severely or extremely anxious. Alcoholism and depression were found to have a statistically significant relationship (p=0.028). During the COVID-19 pandemic, elderly subjects who napped during the day were substantially less depressed (p=0.033). The older the respondents were, the more nervous they were during the pandemic (p=0.042). There is a link between alcohol consumption and stress (p=0.043) and it was seen that females were more stressed as compared to males (p=0.045). There was a strong correlation between participants' alcohol addiction and depressive symptoms. Psychological therapies for the elderly are thought to be necessary to enhance their psychological resilience and mental health. We need to tackle the stigma related to the COVID-19 and mental health issues.

Changes in Peripheral Brachial Blood Pressure from Supine to Lateral Decubitus Position in Hypertensive and Normotensive Subjects

Arterial blood pressure is crucial for supplying the nutritional demands of the all body tissues and is also under tight control for the same. The day to day stress impacts the blood pressure (BP), which is effectively corrected by the baroreceptors mechanism. The effect of lateral decubitus position on the blood pressure with respect to supine position needs to be evaluated as it impacts the haemodynamics. The peripheral brachial blood pressure changes are studied among the normotensives and hypertensives with its significance from change in supine to lateral decubitus position. Sixty (60) normotensives and 60 hypertensive subjects were evaluated for arterial blood pressure measurement using mercury sphygmomanometer by gold standard auscultatory method in the supine, right and left lateral decubitus position. The same observer measured the blood pressure at the similar point of time for all the participants. The Supine and lateral decubitus Systolic and diastolic blood pressure (Mean±SD) parameters were recorded and compared using the paired 't' test (Supine Normotensives SBP 112.5±16.9, DBP 70.1±17.7 mm of Hg; Hypertensives Stage I SBP 130.2±14.5, DBP 85.2±2.8 mm of Hg; Hypertensive Stage II SBP 152.6 ±17.5, DBP 98.4±9.5mm of Hg). The mean and percentage change in systolic and diastolic BP for Normotensives from supine to right lateral position- SBP 11.6 mm of Hg (10.3%), DBP 8.8 mm of Hg (12.5%) and supine to left lateral position SBP 12.5mm of Hg (11.1%), DBP 9.9 mm of Hg (14.1%) p<0.05, for Hypertensives Stage I supine to right lateral position SBP 13.8 mm of Hg (10.5%), DBP 14.8 mm of Hg (17.37%) and supine to left lateral position SBP 13.5 mm of Hg (10.3%), DBP 12.3 mm of Hg (14.13%) p<0.05 and for Hypertensive Stage II from supine to right lateral position SBP 22.6 mm of Hg (14.8%), DBP 16.6 mm of Hg (16.8%), form supine to left lateral position SBP 12.3mm of Hg (8%), DBP 14.7mm of Hg (14.9%) p<0.01) changed significantly among the all the groups with respect to change from supine to lateral decubitus position. The fall in diastolic BP was of greater magnitude than the systolic BP. The right lateral decubitus position was dominant among the hypertensives for producing the change as compared to left lateral decubitus position. However among the normotensives it was left lateral decubitus which produced greater reduction in blood pressure. The lateral decubitus position definitively reduces the blood pressure as compared to supine position and the changes produced can't be simply ascribed to the hydrostatic effect of gravity on blood column. Sleeping on lateral side could thus be advantageous in reducing the arterial blood pressure.

Slow Frequency Anuloma Viloma Pranayama Modulates Cardiac and Neural Oscillations in Yoga Practitioners

Anuloma viloma pranayama (AVP) also known as Alternate nostril breathing (ANB) is the most commonly used form of pranayama, the ancient breath control practice. It is known to modulate cardiovascular control and brain activity. This study analysed the simultaneous recording of Heart rate variability (HRV) and brain activity during and after AVP at a very slow frequency. We carried out an observational cohort study from October 2021 to December 2021 with purposive sample of 30 (Thirty) healthy volunteers involved in regular kriya yoga practice for the last 15 years were inducted into this study AVP involves slow and deep inhalation through one nostril at a time. The ECG for HRV analysis and spectrum of EEG waves were recorded throughout the pre-AVP, during-AVP and post-AVP (each of five-minute duration). The parameters were compared and analysed by repeated measures of analysis of variance with post-hoc analysis using Bonferroni and Holm's multiple comparisons. In time Domain parameters, SDNN and RMSSD were significantly higher during AVP as compared to the pre-AVP and post AVP. In frequency domain parameters total power, LF power, HF power, showed a significant increase during AVP, LF/HF ratio increased during AVP and remained higher post-AVP also. Similarly, Alpha, Beta and Gamma wave power increased significantly during AVP as compared to pre-AVP and post-AVP. The lungs-heart-brain act as coupled oscillators, the analysed data show an increased arousal, attentive and focused state with a negligible change in the heart rate. An overall increased variability in HRV was recorded.

A Study on Psychosomatic Problems Related to the Problematic Internet Use among Adolescents at Selected Schools of Aspur Block, Dungarpur, Rajasthan

Adolescents' scholastic and social life has become increasingly reliant on the internet and mobile technology in recent years. Problematic Internet Use (PIU) is a growing problem in Indian adolescents. However, in many cases, this use has become obsessive, causing them to neglect other elements of their lives. Adolescents account for over 35% of internet users in India. The purpose of this study was to evaluate the psychosomatic problems related to internet overuse among school going adolescent students. This cross-sectional survey was conducted among 348 students in selected schools of Aspur block in Dungarpur-district, Rajasthan, India in the month of February 2016. Problematic internet use (PIU) was assessed by Young's twenty question internet addiction test. The Depression, Anxiety, Stress Scale (DASS-42) and self structured questionnaire check list was used to measure psychosomatic problems among adolescents. Approximately 5.17% adolescents showed Problematic internet use (PIU). Adolescents with PIU were associated with age between 14-16 year, males,10th class of study, using internet since more than 3 years, being at home, mobile as a source of internet use, purpose of internet use with online gaming. Compared with normal internet users, there were significant correlation between Problematic Internet Use and Somatic Complaints r=0.3660, p<0.05, Depression r=0.3982, p<0.05. Anxiety r=0.2512, p<0.05 and Stress r=0.2886, p<0.05. Problematic internet use (PIU) is an increasing problem among teenagers and it has been linked to psychosomatic issues. Timely Effective measures are needed to prevent the spread of this problem.

Health Promoting Lifestyle Profile Assessment among Medical and Nursing Students of Central India

The Health Promoting Lifestyle Profile-II (HPLP-II) is a western-developed questionnaire that assesses 52 health-promoting behaviours (HPB) over six subscales. The purpose of this research was to identify and assess all six components of the Health-Promoting lifestyle Profile among medical and nursing students in central India (AIIMS and Gandhi Medical College, Bhopal). A cross sectional descriptive study was conducted on 619 medical (MBBS/MD/MS) and nursing students of AIIMS and GMC, Bhopal. The online questionnaires were provided to them which consisted of questions from the Health-Promoting Lifestyle Profile II. Health-promoting behaviors differed by gender in MBBS students particularly with respect to Health-Promoting Lifestyle (p=0.009), Health Responsibility (p=0.021), Nutrition (p=0.046) and Physical Activity (p=0.004). Males had significantly higher scores then females. But the difference between males and females was not significant in PG (MD and MS) students. Scores of five out of six scales (except spiritual growth) were found to be higher among nursing students in comparison with medical students (MBBS, MD and MS). These results will raise concerns about lifestyle behaviours and encourage medical and nursing students to evaluate their own health-promoting lifestyles. Physical exercise and diet should be prioritised, particularly for medical students.

Deceased Donor Renal Transplantation: 6 Year Experience from a Tertiary Care Center in North India

The incident of End stage renal disease (ESRD) is rising rapidly worldwide. Renal transplant is the best modality of treatment, offering a better quality of life and mortality benefit, as compared with long-term dialysis. Very few patients have a live renal transplant donor, for rest, a decreased donor renal transplant is the only alternative. Deceased donor renal transplantation (DDRT) programs are only available at few government centers of India, constituting less than 5% of the total renal transplants.

MATERIAL

The patients who had undergone DDRT at our center from February 2015 to February 2021 were registered in the study. The following data were recorded for all patients; age, sex, duration of ESRD, cold ischemia time, type of induction, nadir and follow -up creatinine, hemoglobin, urinary protein and complications. All recipients were followed up and investigated in the outpatient department on a regular basis as per the standard guidelines till death or graft loss, whichever is earlier. Post transplant renal allograft function was measured using serum creatinine and other parameters.

OBSERVATION

During the study period 51 DDRTs were done. There were 40 male and 11 female patients. The mean age was 39.9 ± 9.8 years. The most common cause of ESRD in recipients was chronic glomerulonephritis (CGN) in 92.1 % (47). Amongst the patients, 41 (80.3%) survived, while 10 (19.6%) died post-transplant. Out of ten, 6 recipients died due to early sepsis (&lt;3 months) and 4 died due to late sepsis (&gt;3 months). Acute rejection was present in 17.6 % of patients. Mean post- transplant creatinine in recipients with functioning graft at discharge was 1.54 mg/dl. Graft failure was present in 7 patients out of which 2 were alive at the time of writing this paper and were on maintenance dialysis. Two patients died with a functioning graft. Delayed graft function (DGF) was seen in 13.7% (n=7) of recipients. The causes of DGF in our study included transplant renal artery thrombosis (n=2), Antibody-Mediated Rejection (n=3), mixed rejection (n=1) and Acute cellular rejection (n=1). Among those who had DGF, graft loss was seen in 57.2% (n=4).

CONCLUSION

In our study, the patient survival and graft survival have been better as compared to previous studies and also the number of recipients with delayed graft function have been low. Deceased donor renal transplantation is a practical treatment modality which can drastically improve longevity and quality of life.

Effect of Slow and Deep Breathing on Brain Waves in Regular Yoga Practitioners

Various yogic practices focus on breathing. Breathing may affect brain waves. This cross-sectional study was conducted to see the effect slow and deep respiration on EEG activity in experienced Yoga practitioners at the Department of Physiology at AIIMS, Bhopal, India. The duration of the study was about one year. EEG was taken and was analyzed by Dinamika - Advanced Test System, Moscow, Russia. Paired t-test using graph pad software was used for statistical analysis. The Delta percentage decreased and the other wave's percentages theta, alpha, and beta increased significantly. The person becomes deeply relaxed and more focussed on slow and deep breathing.

Tunnels for Protein Export from the Endoplasmic Reticulum

The functions of coat protein complex II (COPII) coats in cargo packaging and the creation of vesicles at the endoplasmic reticulum are conserved in eukaryotic protein secretion. Standard COPII vesicles, however, cannot handle the secretion of metazoan-specific cargoes such as procollagens, apolipoproteins, and mucins. Metazoans have thus evolved modules centered on proteins like TANGO1 (transport and Golgi organization 1) to engage COPII coats and early secretory pathway membranes to engineer a novel mode of cargo export at the endoplasmic reticulum.

Acute Effects on Heart Rate Variability during Slow Deep Breathing

Slow deep breathing is known to modulate cardiovascular control and is a used in many ancient breath control practices like pranayama. The changes in Heart Rate Variability (HRV) during a less known form of Slow Deep Breathing (SDB) with equal counts of inhalation, holding and exhalation are not well documented. This study analyses the changes during such a slow deep breathing pattern with less than 4 breaths per minute on HRV. The cross sectional descriptive type of observational study was done at AIIMS, Bhopal on 30 regular Kriya yogi volunteers who are practicing for last 10-20 years. SDB involves slow and deep inhalation through the nose, usually to a count of 15, holding for an equal count of 15, followed by slow and complete exhalation for a similar count of 15. The process was repeated for five minutes. The recording ECG for HRV analysis was taken by heart rate variability (Dinamika HRV - Advanced Heart Rate Variability Test System, Moscow, Russia). The resting and during readings of heart rate variability parameters were compared and analysed using a paired t-test. Time domain parameters: Standard Deviation Normal to Normal (SDNN) and Root Mean Square of Successive Differences (RMSSD) were increased at a high level of statistical significance during the manoeuvre. Frequency Domain parameters: Low Frequency (LF), High Frequency (HF), LF/HF ratio increased significantly. Parasympathetic activity is represented by LF when respiration rate is lower than 7 breaths per minute or during taking a deep breath. Thus, when the subject is in the state of relaxation with a slow and even breathing, the LF values can be very high indicating an increase in parasympathetic activity rather than an increase in sympathetic regulation. Practice of pranayama naturally slows the breathing, which in turn makes the heart calmer and calmer as demonstrated by a statistically significant decrease in heart rate after five minutes of SDB. Transient and rapid excitation of cardiovascular system during SDB suggests that the multiple regulatory mechanism at play like mechanical coupling, baroreflex and central mechanisms. Slow yogic breathing (pranayama) may serve as a physiologic method to draw upon cardio-vagal reserve and regular practice of these manoeuvres may beneficially affect cardiovascular autonomic regulation in health and in various cardiovascular diseases.

Factors Affecting Insulin Resistance and Its Relation to Vitamin D Status and Clinical Nutritional Parameters in Dialysis Patients: A Single-center Indian Study

The aim of this study was to measure insulin resistance (IR) in dialysis patients and its relation to Vitamin D status and nutritional parameters. We included patients on maintenance dialysis, both hemodialysis and peritoneal dialysis (HD and PD). IR was measured by homeostatic model assessment (HOMA)-IR index defined as fasting serum insulin (μU/L) × fasting blood sugar (mmol/L)/22.5. Baseline Vitamin D levels were measured by chemiluminescence immunoassay (CLIA) method. HOMA-IR index correlated with nutritional parameters such as 7-point subjective global assessment (SGA) and anthropometric measures, for example, body fat percentage, lean body weight (LBW), mid-arm circumference (MAC), and mid-arm muscle circumference (MAMC). A total of 55 patients were studied, of them 74.55% were male with mean age of the study population being 37.44 ± 14.96 years. The prevalence values of Vitamin D deficiency <30 ngm/ml, <20 ngm/ml, and <10 ngm/ml levels were 96.36%, 70.91%, and 23.64%, respectively. Mean HOMA-IR index was 3.14 ± 3.86. The correlation of HOMA-IR with Vitamin D was negative (r = -0.140, 95% confidence interval [CI] = -0.397-0.138 and P = 0.309); however, in subgroup analysis, patients with Vitamin D level <20 ng/ml had significantly high IR compared to those with Vitamin D >20 ng/ml, i.e., 3.74 ± 4.37 and 1.67 ± 1.47, respectively (P = 0.018). The other measured parameter which had a significant positive correlation with IR was serum uric acid (r = 0.303, 95% CI = 0.021-0.534, and P = 0.025). In nutritional assessment, body mass index, MAC, and MAMC had statistically significant positive correlation with HOMA-IR index (P ≤ 0.001, 0.004, and 0.004, respectively) unlike SGA (P = 0.480). The mode of dialysis did not have a significant effect on IR (HD vs. PD, P = 0.227). The majority of the patients on maintenance dialysis are Vitamin D deficient. Low Vitamin D level, especially <20 ng/ml, muscle mass, and high serum uric acid level are likely to have more IR in dialysis-dependent patients.

How Harmful Can Herbal Remedies Be? A Case of Severe Acute Tubulointerstitial Nephritis

Acute interstitial nephritis (AIN) is a condition in which acute kidney injury (AKI) is characterized by the histological finding of interstitial inflammation. Hyponidd is an ayurvedic drug containing Momordica charantia, Gymnema sylvestre, Swertia chirata, etc., used for the treatment of Type 2 diabetes mellitus (DM) and polycystic ovarian disease as an insulin sensitizer. There are no case reports of AIN caused by this drug yet. We report a biopsy-proven case of AKI due to severe AIN associated with the use of hyponidd tablet in a 60-year-old male with DM and hypertension. As these types of various indigenous compounds are used as home remedies in our country, awareness about the possible adverse effects of these agents among physicians is very important in the early diagnosis and management.

Can Analgesic-abuse Nephropathy is a Fertile Groundfor for Rare Collecting Duct (Bellini Duct) Renal Cell Carcinoma or Merely a Coincidence?

Nonsteroid antiinflammatory drugs have been implicated as nephrotoxic drugs, causing both acute and chronic adverse effects that range from reversible ischemia to chronic kidney disease and urothelial tumors to renal cell carcinoma specially papillary subtype. We report one case of collecting duct (Bellini duct) renal cell carcinoma in patient with analgesic-abuse nephropathy. This young individual was suffering from ankylosing spondylitis since the age of 16 years and was consuming diclofenac and paracetamol (acetaminophen) combination for >15 years. He developed hypertension, secondary glomerulopathy, chronic kidney disease and collecting duct renal cell carcinoma.

A comparative study of central versus posterior approach for internal jugular hemodialysis catheter insertion

Internal jugular (IJ) catheter insertion for hemodialysis (HD) is an indispensable procedure in the management of patients with renal failure. The central approach is favored over posterior approach to insert IJ catheters. There are no studies comparing the outcomes between the two approaches. The aim of this study was to compare central approach with posterior approach for IJ HD catheter insertion and to analyze various outcomes like procedure-related complication rates, catheter insertion failure rates, interruptions during dialysis due to blood flow obstruction and catheter infection rates between the two methods among patients receiving HD. All patients requiring IJ HD catheter insertion during a 1-month period were randomly assigned to undergo catheter insertion via either conventional central approach or posterior approach. Patients were followed-up till the removal of the catheter. Among 104 patients included in the study, 54 were assigned to the central approach group and 50 to the posterior approach group. The central approach group had higher rate of procedure-related complications (14.81% vs. 6%, P = 0.04). Catheter insertion failure rates were marginally higher in posterior approach group (20% vs. 12.96%, P = 0.07). One or more instance of interruption during HD due to obstruction in blood flow was more common in posterior approach (46% vs. 9.25%, P < 0.01). Catheter infection rates were similar between the two groups; 16.66% (n = 9) in central group vs. 14% (n = 7) in posterior group. Posterior approach is a reasonable alternative to conventional central approach in IJ cannulation for HD catheter. It is, however, associated with a significantly high rate of interruption in HD blood flow and catheter insertion failure rates. The posterior approach can be used in patients with local exit site infection or in failed attempts to cannulate IJ vein via the conventional central approach.

Periodic Peritoneal Dialysis in End Stage Renal Disease: Is it Still Relevant? A Single Center Study from India

BACKGROUND

High cost of maintenance hemodialysis (HD) and continuous ambulatory peritoneal dialysis (PD) in India has made renal replacement therapy out of reach of many patients with end stage renal disease (ESRD). Repeated puncture PD although inferior to HD biochemically, is easily and freely available across Rajasthan, India, and is simple to perform, and does not require sophisticated machines, thus making it an attractive option for dialysis for ESRD.

AIM

To analyze the outcomes of periodic PD in patients with ESRD requiring dialysis support.

SUBJECTS AND METHODS

A prospective study analyzing the data of patients who underwent PD between August 2010 and January 2013 in Sawai Man Singh Hospital, Jaipur, India was conducted. Patients were divided into three groups based on the time period between first and second session of PD. Detailed demographic and clinical data during the study period were collected along with PD related complications. The main outcome studied was technique survival 1 year post initiation of PD.

RESULTS

234 patients received an initial session of PD, of which 174 had a good response and were included in the study. 19 patients received the second PD within 7 days of first (Group 1), 45 patients within 8-14 days (Group 2) and 110 patients within 15-21 days (Group 3). The overall 1 year technique survival was 68.4% (91/133), with a rate of 50% (5/10), 56.8% (21/37), and 75.6% (65/86) for Group 1, Group 2, and Group 3, respectively. The time duration between first and second PD proved to be reliable indicator of the subsequent response, with a technique survival rate significantly lower in Group 1 patients compared to Groups 2 and 3 (P = 0.04). Median dialysis free days were 11, 16 and 21 days in Group 1, Group 2, and Group 3, respectively. Peritonitis rate observed was 2.1% (49/2261) during the study period.

CONCLUSION

Periodic PD is a simple, safe and cheap procedure, which can be considered as used as a palliative measure in terminal uremia in underprivileged areas.

Incidence and profile of C3 Glomerulopathy: A single center study

C3 glomerulopathy has recently been described as a distinct entity. The underlying mechanism is unregulated activation of the alternate pathway of the complement system. The most common presentation is with an acute nephritic syndrome. The diagnosis is made on immunofluoroscence by the presence of isolated or dominant C3 staining. In this retrospective study, renal biopsy data were collected from 2010 to 2013 patients with C3 glomerulopathy identified and their clinical and biochemical parameters analyzed. Out of 514 biopsies available for analysis, the incidence of C3 glomerulopathy was 1.16% (n = 6). The mean age of the presentation was 26 years and the average estimated glomerular filtration rate was 30.65 ml/min/1.73 m(2). The most common histopathological pattern was membranoproliferative glomerulonephritis (n = 4).

Lepromatous leprosy: An Unusual Presentation

A 25 year old man presented with loss of sensations over both hands and feet and extreme difficulty in passing urine. On examination, an indurated sclerotic plaque was present on shaft of penis and scrotum in addition to other features of lepromatous leprosy. Skin biopsy from the penile lesion showed presence of a large number of acid fast bacilli with a BI of 6+ extending into the epidermis and histopathology showed absence of Grenz zone and presence of foamy macrophages in the dermis up to the dermo-epidermal junction.

Renal cortical necrosis: A rare complication of Plasmodium vivax malaria

A young female with Plasmodium vivax malaria presented with anemia, hyperbilirubinemia, thrombocytopenia, and advanced renal failure. She remained anuric for more than 3 weeks. Kidney biopsy confirmed the diagnosis of acute cortical necrosis. During follow-up, she became dialysis independent, but remained in stage 4 chronic kidney disease (CKD) at 3 month. P. vivax is supposed to be benign in nature, but can lead to rare and severe complication like renal cortical necrosis and progress to CKD.

Renal tubular dysfunction presenting as recurrent hypokalemic periodic quadriparesis in systemic lupus erythematosus

We report recurrent hypokalemic periodic quadriparesis in a 30-year-old woman. Patient had also symptoms of multiple large and small joint pain, recurrent oral ulceration, photosensitivity and hair loss that were persisting since last 6 months and investigations revealed systemic lupus erythematosus (SLE) with distal tubular acidosis. Our patient was successfully treated with oral potassium chloride, sodium bicarbonate, hydroxychloroquine and a short course of steroids. Thus, tubular dysfunction should be carefully assessed in patients with SLE.

Esophageal histoplasmosis in a renal allograft recipient

Histoplasmosis is a progressive granulomatous disease caused by the intracellular dimorphic fungus Histoplasma capsulatum. We report a rare case of esophageal histoplasmosis in a renal allograft recipient. A 55-year-old male who received a live, unrelated renal allograft 20 years ago presented with complaints of recurrent fever for ten to 12 months, weight loss over six months, progressive dysphagia more for solids for five to six months and joint pain and swelling involving the bilateral metacarpo-phalangeal and proximal interphalangeal joints. Biopsy from the esophageal ulcers revealed dense inflammation infiltrated with lymphocytes and macrophages with clusters of strongly positive intracellular fungal spores with a clear area or "halo-like" zone suggestive of Histoplasma capsulatum invasion. The patient was treated with intravenous liposomal amphotericin B for ten days and later switched over to oral itraconazole. Repeated endoscopy revealed significant improvement of the lesions.

Unusual foreign bodies in ear, nose and throat practice

Ear, Nose and Throat practice presents the surgeons with an amazing variety of foreign bodies to deal with, some of them truly unusual. Presented here are two cases with foreign bodies unusual in nature, extracted by improvisation.

Acute mixed cellular and humoral rejection of renal allograft with leucopenia

Diagnosis and management of acute renal allograft dysfunction often pose challenge to nephrologists during practice. Acute rejection is a major cause of acute graft dysfunction but is rare in patients with leucopenia. Acute rejection can have either humoral or cellular components or sometimes mixed components. Mixed acute cellular and humoral rejection often present as steroid resistant rejection. Here we report a patient with live related renal transplant recipient with acute graft dysfunction with leucopenia who was found to have mixed acute cellular and humoral rejection.

Effect of alternate nostril breathing exercise on cardiorespiratory functions

Pranayama (breathing exercise), one of the yogic techniques can produce different physiological responses in healthy individuals. The responses of Alternate Nostril Breathing (ANB) the Nadisudhi Pranayama on some cardio-respiratory functions were investigated in healthy young adults. The subjects performed ANB exercise (15 minutes everyday in the morning) for four weeks. Cardio-respiratory parameters were recorded before and after 4-weeks training period. A significant increment in Peak expiratory flow rate (PEFR L/min) and Pulse pressure (PP) was noted. Although Systolic blood pressure (SBP) was decreased insignificantly, the decrease in pulse rate (PR), respiratory rate (RR), diastolic blood pressure (DBP) were significant. Results indicate that regular practice of ANB (Nadisudhi) increases parasympathetic activity.

Visceral leishmaniasis masquerading as chronic liver disease

We report a patient with fever, progressive jaundice and abdominal distension, having marked pallor, icterus, ascites and hepatosplenomegaly. Investigations revealed pancytopenia and deranged liver functions. Doppler study revealed portal hypertension and endoscopy showed grade II oesophageal varices. Liver biopsy suggested leishmanial hepatitis and bone marrow demonstrated multiple LD bodies. Diagnosis of "visceral leishmaniasis with leishmanial hepatitis with portal hypertension" was made. The case is being reported because of its rarity apart from it being an unusual presentation of kala-azar.

Emphysematous pyelonephritis: report of 4 cases

Emphysematous pyelonephritis is a rare, life endangering suppurative infection of the renal parenchyma and perirenal spaces. The disease is encountered mainly in patients with diabetes mellitus and is characterized by the production of intrarenal and, occasionally, perirenal gas. We present 4 cases of emphysematous pyelonephritis encountered in our hospital with review of the literature.

Profile of chronic hepatitis B virus in children in India: experience with 116 children

BACKGROUND

Hepatitis B virus (HBV) infection in children is mostly asymptomatic and therefore the disease burden is likely to be under appreciated. There is limited information on the profile of chronic HBV infection in children from the Indian subcontinent.

METHOD

In 116 (male:female 89:27) children, aged <15 years, with persistent HBsAg positivity for more than 6 months, a clinical, biochemical, virological and histological assessment was carried out.

RESULTS

At presentation, 21.6% of children were symptomatic, with icterus in 12%. Features of decompensation such as ascites (7%) and gastrointestinal (GI) bleed (5%) were noted uncommonly. Five (4.3%) children had hepatocellular carcinoma (HCC) at presentation. Elevated alanine aminotransferase (ALT) was observed in 76% of subjects (median 61; range 14-815). A significantly higher proportion of children with hepatitis B early antigen (HbeAg) positive status had higher histological activity index (HAI) (84% vs 16%, P < 0.001) and fibrosis score (80% vs 20%, P = 0.007). A strong positive correlation was noted between aspartate aminotransferase (AST), ALT, HBV-DNA and histological severity of the disease (HAI > or =4, fibrosis > or =2). Median HBV-DNA levels were significantly higher in the HBeAg positive compared to the HBeAg negative group (25.6 vs 0.7 pg/mL, P = 0.004). Seventy-four percent of the mothers had evidence of past or present HBV infection.

CONCLUSIONS

Majority of the children with chronic HBV infection are asymptomatic at presentation. HBeAg positive status reflects histologically more severe disease, and a higher level of HBV-DNA. Almost two-thirds of the children may have acquired their HBV infection perinataly.

Primary parotid tuberculosis: varied clinical presentations

Parotid gland tuberculosis is rare and may present in different clinical forms. We present three cases of tuberculosis of the parotid gland that presented to us with different clinico-pathological appearances. The cases were diagnosed on the basis of histopathological evaluation and fine needle aspiration cytology. All the patients responded to four-drug antitubercular chemotherapy.

Transmission of G145R mutant of HBV to an unrelated contact

Household contacts of HBV-related chronic liver disease patients constitute a high-risk group for acquisition of HBV infection. Some of the HBsAg mutants are associated with liver disease and some are reported to be transmitted vertically. There is limited information on the horizontal transmission of Gly 145 Arg (G145R) mutant to related contacts. Its possible transmission to an unrelated third degree contact is reported in the present study. An HBV related chronic liver disease patient; the index patient, and his 11 household contacts were studied. This included four 1 degrees, three 2 degrees, one 3 degrees, and a sexual contact. Surface gene sequencing including the "a" determinant region was carried out in HBV DNA+ve subjects. The sequences were aligned and compared for the homology. HBV DNA was found to be positive in one 1 degrees, three 2 degrees, and one 3 degrees contact, besides the index patient. Histopathological studies revealed evidence of chronic hepatitis in all these contacts. Mutation T118V was present in all the six subjects. Mutant G145R along with T118V and T143M was identified in three subjects who included one 1 degrees, one 2 degrees, and one 3 degrees contact. Presence of T118V and T143M mutations along with G145R mutation in these subjects provides an indirect evidence for the possible horizontal transmission of G145R HBV variant to a 3 degrees unrelated contact. Of these three contacts with G145R mutation, only one 1 degrees contact was found to be HBsAg-ve. The data also reaffirms the earlier finding of HBsAg positivity in presence of G145R mutation of the S-gene. HBV exists as quasi-species and mixed population in subjects with chronic HBV infection.

Smear morphology of cryptococcosis presenting as a subcutaneous swelling in healthy adults: a report of three cases

OBJECTIVE

To highlight the various morphological smear pattern in cases of subcutaneous Cryptococcus infection in healthy adults.

METHOD

Cryptococcus is an opportunist fungus and primary infection is acquired through respiratory tract. Dissemination by blood stream results in systemic infection. Ten to 15% of systemic infection present as cutaneous lesions. Between December 2002 and April 2004 three healthy adults presented to us consecutively with subcutaneous swelling.

RESULTS

We diagnosed these cases on FNAC as Cryptococcus. In all the three patients there was no history of local penetrating injury and any signs or symptoms of systemic disease. They were two male and one female, immuno competent and were negative for HIV 1 & 2 tested by ELISA. The sites were right abdominal flank, occipital and left anterior upper thigh. Aspirated materials were oily fibro fatty tissue and necrotic purulent materials. Cryptococcus numbers varied in all the smears so also their size and capsule thickness. Background smear morphology and tissue reaction were also different. It could be gelatinous, granulomatous, and cellulitic response or mixed responses and this can be picked up on cytological smears. Cultures were confirmatory in all the three cases. These lesions were resolved with antifungal treatment.

CONCLUSION

Our brief article highlights the morphological spectrum on FNAC smears and diagnostic problems faced in these uncommon circumstances where the aspirates were purulent and the yeasts were small, few and thin walled. In the acute inflammatory smear with occasional giant cells and/or granulomas special stains like PAS or Mucicarmine are necessary to look for budding yeast of Cryptococcus with thin neck.

Beneficial effects of 'lamivudine pulse' therapy in HBeAg-positive patients with normal ALT*

Currently no therapy is given to patients with chronic hepatitis B virus (HBV) infection who are HBeAg positive with normal alanine aminotransferase (ALT) levels. Steroid priming has been shown to enhance T-helper-1 (Th-1) cell response. Lamivudine may restore immunologic competence against HBV by causing a sudden decline in the level of the virus. We examined the efficacy of lamivudine pulse therapy on the seroconversion from HBeAg to anti-HBe. This was a prospective single-blinded trial including 27 patients with chronic hepatitis B, HBeAg positive with ALT < or =1.5 times upper limit of normal (ULN). Lamivudine was administered initially for 4 weeks, then stopped for 2 weeks and later restarted and continued till 3 months after seroconversion or completion of 2 years of therapy. Twenty-six patients completed the study. Lamivudine withdrawal led to a rise in ALT levels above the ULN in 11 (42.3%) patients at 6 weeks; seven of them (63.6%) lost HBeAg compared with only two of the 15 patients (13.3%), in whom ALT levels did not rise (P = 0.011). As one patient showed a relapse, a total of eight (31%) patients responded to lamivudine pulse therapy over a mean period of 17.3 +/- 4.5 months. Responders had a higher serum albumin (P < 0.05), a lower fibrosis score (P < 0.05), and a relatively high baseline serum ALT levels (P = 0.024) than the nonresponders. YMDD mutations developed in three patients and none responded. No patient developed hepatic decompensation. Hence lamivudine pulse therapy has potential in converting HBeAg-positive, 'not-treat-worthy' (ALT < 1.5 ULN) patients to treat-worthy (ALT > 1.5 ULN) in 42%, with sustained HBeAg and HBV DNA loss in 31% patients. The effects are possibly because of a combination of antiviral and immunomodulating activities of lamivudine.

Seborrheic keratosis of the conjunctiva

Seborrheic keratosis can simulate a malignant melanoma and should form the differential diagnosis of a malignant melanoma. Histopathology is confirmatory.

Role of yoga in modifying certain cardiovascular functions in type 2 diabetic patients

OBJECTIVES

1. To study the effect of forty days of Yogic exercises on cardiac functions in Type 2 Diabetics. 2. To study the effect of forty days of Yogic exercises on blood glucose level, glycosylated hemoglobin.

METHODS

The present study done in twenty-four Type 2 DM cases provides metabolic and clinical evidence of improvement in glycaemic control and autonomic functions. These middle-aged subjects were type II diabetics on antihyperglycaemic and dietary regimen. Their baseline fasting and postprandial blood glucose and glycosylated Hb were monitored along with autonomic function studies. The expert gave these patients training in yoga asanas and they pursued those 30-40 min/day for 40 days under guidance. These asanas consisted of 13 well known postures, done in a sequence. After 40 days of yoga asanas regimen, the parameters were repeated.

RESULTS

The results indicate that there was significant decrease in fasting blood glucose levels from basal 190.08 +/- 18.54 in mg/dl to 141.5 +/- 16.3 in mg/dl after yoga regimen. The post prandial blood glucose levels decreased from 276.54 +/- 20.62 in mg/dl to 201.75 +/- 21.24 in mg/dl, glycosylated hemoglobin showed a decrease from 9.03 +/- 0.29% to 7.83 +/- 0.53% after yoga regimen. The pulse rate, systolic and diastolic blood pressure decreased significantly (from 86.45 +/- 2.0 to 77.65 +/- 2.5 pulse/min, from 142.0 +/- 3.9 to 126.0 +/- 3.2 mm of Hg and from 86.7 +/- 2.5 mm of Hg to 75.5 +/- 2.1 mm of Hg after yoga regimen respectively). Corrected QT interval (QTc) decreased from 0.42 +/- 0.0 to 0.40 +/- 0.0.

CONCLUSION

These findings suggest that better glycaemic control and stable autonomic functions can be obtained in Type 2 DM cases with yoga asanas and pranayama. The exact mechanism as to how these postures and controlled breathing interact with somato-neuro-endocrine mechanism affecting metabolic and autonomic functions remains to be worked out.

Gangliogliomas: A report of five cases

Gangliogliomas are rare tumors of the Central Nervous System. Five gangliogliomas were diagnosed out of 1560 brain tumours surgically resected out in a period of 5 years accounting for 0. 32%. We have tried to discuss in detail the pathological features of these tumours and have mentioned the clinical and radiological features associated with them. All the slides, tissue blocks and pathology reports of the surgical specimens of gangliglioma were reviewed and the clinical and radiological data reviewed. The ages of the patients ranged from 7-65 years with 4 males and 1 female. The tumors were located in the lateral ventricle (a rare site), temporal, parietal and the frontal lobes with duration of seizures varying from 1-9 years. The tumors were diagnosed by the presence of a dual population of neoplastic ganglionic and glial components. The glial components consisted of pilocytic astrocytes (l case), fibrillary astrocytes (2 cases), oligodendrocytes (1 case) and anaplastic astrocytes and oligodendrocytes (1 case). There was one-grade I GG, three-Grade II GGs and one-grade III GG. Astrocytes were the commonest glial component of GGs, either pilocytic or fibrillary. Oligodendrocytes as the glial component of GGs was seen in 2 cases one of which was anaplastic and this is a rare finding.

Absence of hemochromatosis associated Cys282Tyr HFE gene mutation and low frequency of hemochromatosis phenotype in nonalcoholic chronic liver disease patients in India

BACKGROUND AND AIM

Hereditary hemochromatosis (HHC) is an autosomal recessive disorder causing primary iron overload syndrome and chronic liver disease (CLD). This genetic disease is commonly associated with C282Y mutation of the HFE gene, commonly seen in the Northern European population. Minor reports on HHC are available from Asia, however, so far no genetic study is available from India. We prospectively studied the prevalence of C282Y mutation in CLD patients and healthy subjects in a tertiary care referral center in India.

METHODS

A total of 249 consecutive biopsy proven CLD (HBV = 112, HCV = 72, cryptogenic = 65) patients and 134 age matched healthy controls were included. Cases of secondary iron overload, pregnancy, chronic alcoholism, age < 30 years and hepatocellular carcinoma (HCC) were excluded. A transferrin saturation index (TSI) of >60% was suggestive of a phenotypic presentation of HHC. C282Y mutation was studied by restriction fragment length polymorphism (RFLP) using genomic DNA. The 387 bp fragment obtained after polymerase chain reaction was digested with 10 units of endonuclease Rsa1. The mutation was detected by creation of an additional restriction site, giving rise to fragments of 247 111 and 29 bp.

RESULTS

While the mean TSI was comparable, serum ferritin was significantly higher in CLD patients compared to controls (38 +/- 16%vs 28 +/- 13%; p = not significant (NS), and 125 +/- 18 vs 42 +/- 25 ng/mL; p < 0.001). A TSI of >60% was detected in 24 (9.64%) patients. Only one restriction site was found for endonuclease Rsa1, giving rise to two fragments of 247 and 140 bp, suggesting absence of C282Y mutation in the HFE gene in all patients.

CONCLUSIONS

Almost 10% of nonalcoholic CLD patients in India have iron overload, but this is independent of C282Y mutation of the HFE gene. Large population based studies are recommended to investigate the prevalence of this rare disorder in India.

Hepatic dysfunction in patients with extrahepatic portal venous obstruction

BACKGROUND

Extrahepatic portal venous obstruction (EHPVO) developing due to thrombotic occlusion of the portal vein in children is generally considered a benign disease. Whether hepatic dysfunction develops in these patients in the absence of a gastrointestinal bleed has not been well studied.

MATERIALS AND METHODS

Forty-three patients with EHPVO who had not bled in the last 3 months were studied. Patients were divided into those with (group I) or without ascites (group II). Matched cirrhotic patients with ascites (group III) served as controls. Clinical, biochemical, ultrasonographic, and histopathological evaluation was carried out. Portal biliopathy was assessed in five patients in group I and in 12 patients in group II by cholangiography.

RESULTS

Of 43 EHPVO patients, ascites was seen in nine (21%) patients (group I). Thirty-four patients had no ascites (group II). Serum ALT (54 +/- 24 vs. 34 +/- 10 IU/l, P < 0.01), albumin (3.2 +/- 0.3 vs. 3.7 +/- 0.4 g/dl, P < 0.01), and prothrombin time difference (9.0 +/- 4.5 vs. 2.4 +/- 1.9 s, P < 0.05) were deranged in patients in group I compared with group II. Patients in group I were 4 years older, and the duration of portal hypertension was longer than in group II (11.5 vs. 5.6 year, P < 0.05). Portal biliopathy changes were significantly more severe in group I than in group II patients. Ascites was high gradient in all the patients in group I and the serum-ascitic albumin gradient was comparable between groups I and III. None of the EHPVO patients, but four cirrhotic patients, developed spontaneous bacterial peritonitis during a follow-up of 11 +/- 4 months.

CONCLUSIONS

Hepatic dysfunction in the form of ascites and deranged liver functions is not uncommon in patients with EHPVO, more so in patients with prolonged portal hypertension. Based on our data it would be worthwhile to study whether prolonged portal vein thrombosis in EHPVO patients could lead to progressive liver disease.

Neurophysiology of pain: insight to orofacial pain

This is a very exciting time in the field of pain research. Major advances are made at every level of analysis from development to neural plasticity in the adult and from the transduction of a noxious stimulus in a primary afferent neuron to the impact of this stimulus on cortical circuitry. The molecular identity of nociceptors, their stimulus transduction processes and the ion channels involved in the generation, modulation and propagation of action potentials along the axons in which these nociceptors are present are being vigorously perused. Similarly tremendous progress has occurred in the identification of the receptors, transmitters, second messenger systems, transcription factors, and signaling molecules underlying the neural plasticity observed in the spinal cord and brainstem after tissue or nerve injury. With recent insight into the pharmacology of different neural circuits, the importance of descending modulatory systems in the response of the nervous system to persistent pain after injury is being reevaluated. Finally, imaging studies revealed that information about tissue damage is distributed at multiple forebrain sites involved in attentional, motivational, and cognitive aspects of the pain experience.

Rabbit model of non-cirrhotic portal fibrosis with repeated immunosensitization by rabbit splenic extract

BACKGROUND

Non-cirrhotic portal fibrosis (NCPF) or idiopathic portal hypertension, a disease of unknown etiology, is a common cause of portal hypertension in developing countries. Attempts to understand the etiopathogenesis of NCPF by developing animal models have been made. We describe a novel approach using repeated injections of rabbit splenic extract that were obtained from a previously primed rabbit, to develop a model of NCPF.

METHODS

Twenty-eight rabbits (1.5-2.0 kg) were divided into the control (group I, n = 13) and the experimental (group II, n = 15) groups. The supernatant obtained after centrifugation of a 20% splenic homogenate, containing 6 mg protein/mL, was mixed with Freund's complete adjuvant (1:1 ratio) and injected intramuscularly to the recipient rabbits every 2 weeks for 3 months. Portal pressure was measured by inserting a cannula into the gastrosplenic vein.

RESULTS

The mean portal pressure in group II was significantly (P < 0.05) higher than group I at 1 (19.4 +/- 2.9 vs 10.4 +/- 2.2 mmHg), 3 (16.7 +/- 1.1 vs 7.2 +/- 3.6 mmHg), and 6 (20.3 +/- 5.4 vs 10.3 +/- 4.8 mmHg) months. The mean splenic weight in group II was significantly (P < 0.05) greater than group I at 1, 3 and 6 months. Histopathology of spleen showed medullary congestion, hemosidrin laden macrophages and mild fibrosis. Liver showed normal hepatocytes with mild portal lymphocytic infiltrates and Kupffer cell hyperplasia. No significant anomalies were observed in the tests of liver function at 1 and 6 months.

CONCLUSIONS

This animal model showed significant splenomegaly, with persistent rise in portal pressure without hepatic parenchymal injury, quite akin to NCPF seen in humans. This study also proposes that repeated immunostimulation may have an important role in the pathogenesis of NCPF.

Mediastinal enteric duplication cyst containing aberrant pancreas

OBJECTIVE

The purpose of the study is to report a unique association of clinical and pathological findings in a neonate. Foregut enteric duplication cysts--rare developmental anomalies that are associated with midline vertebral fusion anomalies.

METHODS

We had a neonate with foregut duplication cyst who presented at birth with respiratory distress. The child also had associated communicating hydrocephalus. The patient underwent excision of the duplication cyst along with a ventriculo-peritoneal shunt.

RESULT

The excised specimen revealed a duplication cyst lined by aberrant pancreatic tissue.

CONCLUSION

The present case demonstrates histologically the presence of both pancreatic and gastric tissue.