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Caesarean delivery is common and can cause severe postoperative pain but injection of local anaesthetic at various sites for regional blocks or local anaesthetic infiltration may reduce this. We aimed to compare and rank these sites. We searched PubMed, Google Scholar, EMBASE and CENTRAL to June 2021 for randomised controlled trials and performed a random-effects Bayesian model network meta-analysis. The primary outcome was dose of parenteral morphine equivalents in the first 24 postoperative hours. We used surface under cumulative ranking probabilities to order techniques. We analysed 114 trials (8730 participants). The ordered mean (95% credible interval) reduction in morphine equivalents, from 34 mg with placebo, were as follows: ilio-inguinal 15 (1-32) mg; ilio-inguinal-iliohypogastric 13 (6-19) mg; transversalis fascia 11 (4-26) mg; erector spinae 11 (10-32); transverse abdominis 9 (4-13) mg; wound catheter infusion 8 (2-15) mg; quadratus lumborum 8 (1-15) mg; wound infiltration 8 (2-13) mg; and no intervention -4 (-10 to 2) mg. Ordered efficacies for injection sites were different for other relevant outcomes, including pain (to 4-6 h and to 24 h) and time to rescue analgesia: there was no single preferred route of injection. The ordered mean (95% credible interval) reduction in dynamic pain scores (0-10 scale) at 24 h compared with placebo were as follows: wound infusion 1.2 (0.2-2.1); erector spinae 1.3 (-0.5 to 3.1); quadratus lumborum 1.0 (0.1-1.8); ilio-inguinal-iliohypogastric 0.6 (-0.5 to 1.8); transverse abdominis 0.6 (-0.1 to 1.2); wound infiltration 0.5 (-0.3 to 1.3); transversalis fascia -0.8 (-3.4 to 1.9); ilio-inguinal -0.9 (-3.6 to 1.7); and no intervention -0.8 (-1.8 to 0.2). We categorised our confidence in effect sizes as low or very low.

Purpose The present work reports effects of source step sizes on dose distribution in patients treated with cobalt-60 (Co-60) high-dose-rate afterloading brachytherapy in carcinoma cervix (Ca-cx). Methods and Materials The retrospective study is based on data of 15 patients of Ca-cx treated with Co-60 high-dose-rate intracavitary brachytherapy with dose of 21 Gy in three fractions with source step size of 2.5 mm after external beam radiotherapy of 46 Gy. The effect of source step size on overall treatment procedure was evaluated from prescribed dose volume, dose to organ at risks, and treatment time for source step sizes of 1 mm, 2.5 mm, 5 mm, and 10 mm for each patient. Results The mean dose to bladder point for 1 mm, 2.5 mm, 5 mm, and 10 mm source step sizes was found to be 3.37 Gy (SD: 1.36), 3.44 Gy (SD: 1.38), 3.54 Gy (SD: 1.41), and 3.74 Gy (SD: 1.46), respectively. Similarly, the mean dose received by rectum point for these source step sizes were 2.86 Gy (SD: 0.64), 3.02 Gy (SD: 0.67), 3.25 Gy (SD: 0.71), and 3.63 Gy (SD: 0.73), respectively. The treatment time and prescribed dose coverage volume were both found to be gradually increasing with increase in step size. Conclusions Our results on Ca-cx brachytherapy using Co-60 source indicate that the prescribed dose volume gradually increases from smaller source step to larger source step size. This results in increase of dose to the bladder and rectum and may lead to increase in toxicity and reduces quality of life. The study recommends that step size more than 5 mm should not be used for uterine cervix intracavitary application using Co-60 source.

Variable doses of intrathecal fentanyl (ITF) have been used for peri-operative analgesia during cesarean delivery (CD). We conducted a systematic review and meta-analysis to compare lower doses (LD; ≤12.5 µg) and higher doses (HD;12.5 µg) of ITF in parturients undergoing CD.Databases were searched from inception to December 2020 for randomized controlled trials (RCTs) administering ITF as an additive to local anesthetic. The primary outcome was the use of intra-operative analgesic supplementation. Time to first rescue analgesia, the incidence of peri-operative side effects and neonatal outcomes were secondary outcomes. Additional analysis was performed after stratifying trials using ≤15 µg and15 µg of ITF. Mean difference (MD) and risk difference (RD) with 95% confidence interval (CI) were calculated.Eleven RCTs met inclusion criteria. Study groups were 601 patients (LD) and 749 patients (HD). A HD of ITF reduced the risk for supplementation by 6% (95% CI 0 to 13%; P=0.05; IIn women undergoing CD, doses of ITF12.5 µg reduced the requirement for intra-operative analgesic supplementation and prolonged the time to first rescue analgesia compared with smaller doses, but increased pruritus. On revising the cut-off to 15 µg, no significant difference was found.

INTRODUCTION There are limited data on the effect of chronic pancreatitis (CP) on pregnancy outcomes and vice versa. Our aim was to evaluate the clinical trajectory of CP during pregnancy and its effect on pregnancy outcomes. METHODS All female patients of child-bearing age (≥15 years) diagnosed with CP were studied from January 2004 to July 2019. The change in frequency of painful episodes was assessed before, during, and after pregnancy. Maternal and fetal outcomes were compared between pregnant women (early onset) and women presenting with CP after completion of all pregnancies (late onset). RESULTS Of 187 women with CP, pregnancy outcomes and clinical course were assessed in 99 patients. The frequency of painful exacerbations was significantly lower during pregnancy compared with prepregnancy and postpregnancy periods (P < 0.001). The median pain score decreased significantly to 0 (0-2) during pregnancy from 3 (0-6) before conception and increased to 4 (0-8) after pregnancy (P = 0.002). Women with early onset CP (n = 57) had their first child later and had fewer pregnancies compared with those with late onset CP (n = 42). There was no difference in maternal outcomes such as gestational diabetes, hypertension, and preterm delivery, and fetal outcomes such as abortion, low birth weight, and still birth between the groups. There was no reported congenital anomaly. DISCUSSION Younger patients with CP had later and fewer pregnancies, but there was no increased risk of adverse maternal and fetal outcomes. The clinical course of CP was usually benign during pregnancy with decreased frequency and severity of pain.

Aim and objectives The paucibacillary nature of pediatric tuberculosis (TB) makes diagnosis difficult. The aim of the study was to correlate the clinical spectrum of pediatric TB with microbiological diagnosis. Materials and methods Specimens from clinically suspected pediatric TB cases were subjected to Ziehl-Neelsen staining, culture on Lowenstein-Jensen medium and cartridge-based nucleic acid amplification test (CB-NAAT) for TB. Results Pulmonary TB was the predominant form affecting 36 of 62 (58%) patients. Tubercular meningitis was the commonest form of extrapulmonary type and affected 13 of 26 (50%) children. Microbiological diagnosis by any of the above methods could be established in 35 (56.45%) cases. While 33 of 36 (92%) patients diagnosed with pulmonary TB had radiological findings, of which only 25 (76%) could be microbiologically confirmed, only 24 of 31 (77%) patients with extrapulmonary symptoms had radiological evidence and microbiological confirmation could be achieved in 4 (17%) of these. Conclusion An integrated approach of diagnosis, including clinical-radiological, microbiological and immunological evidence should be stressed on.

The present work reports data of the radiation exposure to the patient in various diagnostic and therapeutic interventional radiological (IR) procedures. The study includes 260 diagnostic and 195 therapeutic exposure data in 455 IR procedures. All the IR procedures were performed on a biplane angiographic machine in a tertiary care hospital. The radiation exposure was estimated from dose-area product (DAP), fluoroscopy time (FT), number of fluoroscopic runs, number of images and cumulative dose (CD) value recorded during the procedure. The data reported in the present study show significant variability in DAP values in diagnostic and therapeutic IR procedures. In diagnostic procedures, the minimum median DAP value is 8.93 Gy cm2 for upper limb angiography with mean FT of 2.7 min and maximum DAP value is 108.8 Gy cm2 for inferior vena cava angiography with mean FT of 12.55 min. For therapeutic procedures, the median value of DAP ranges from 2.43 Gy cm2 for sclerotherapy with mean FT 0.65 min to 267.23 Gy cm2 for coiling of cerebral aneurysm with mean FT of 60.52 min. The DAP value for each procedure was also correlated with FT, number of fluoroscopic runs, number of images and CD. The reported DAP values in this study are within the range of earlier published results which suggest that our finding provides at least approximate applicability to other hospitals. The third quartile DAP values of the procedures having significant number of patient data (n ≥ 10) serves as provisional reference values for the optimization of procedure protocols.

The aim of this study was to compare combined hormonal vaginal ring with ultralow-dose combined oral contraceptive (COC) pills in management of heavy menstrual bleeding (HMB). Fifty patients were randomised into Group I: vaginal ring (n = 25) and group II: COC pills (n = 25). Menstrual blood loss (MBL) was assessed at baseline, 1, 3 and 6 months (while on treatment) and at 9 months (3 months after stopping therapy). There was significant reduction in baseline pictorial blood loss assessment chart (PBAC) score from 440 ± 188 (Mean ± SD) to 178 ± 95, 139 ± 117, 112 ± 84 and 120 ± 108 in group I and from 452 ± 206 to 204 ± 152, 179 ± 125, 176 ± 164 and 202 ± 167 in group II at 1, 3, 6 and 9 months, respectively (p = 0.001). Reduction in MBL was 72% and 62% at 6 months and up to 71% and 55% at 9 months in group I and group II, respectively (p = 0.001). Reduction in MBL with ring was greater at higher baseline PBAC score but lesser in patients with fibroid > 2 cm. Combined vaginal hormonal treatment for HMB is as effective as oral hormonal therapy, with minor and transient side effects and persistence of response after cessation of therapy.

Over recent years, the field of medicine has been challenged by the twin epidemic of heart failure and renal insufficiency. The coexistence of the two problems in the same patient, referred to as cardiorenal syndrome (CRS), is defined as 'disorders of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other. The mechanisms underlying this interaction are complex and multifactorial in nature.Identify and classify patients admitted with cardiorenal syndrome into various subtypes and assess clinical outcome at discharge and at three months.Ours was a longitudinal study of 50 patients admitted in ICU with CRS. They were classified as per RONCO classification (2008) into various subtypes. Outcomes was addressed as favourable for patients stable at discharge and at 3 months follow up, whereas outcome was termed non-favourable for patients who expired or initiated on hemodialysis.Of 50 patients, two-third patients were males (66%), with mean age of males and females being 64.18 years and 64.64 years respectively. Majority of the patients had Type-1 CRS (46%) followed by twenty two percent Type-2, twenty six percent type-4 and six percent Type-5. There were no patients with type-3 CRS. At the end of the study, 24 (48%) patients were stable, 12 (24%) required dialysis and 14 (28%) patients had expired. The total non-favourable outcomes (dialysis / death) were higher with subtypes CRS-4 (n-11, 22%) and CRS-1 (n-8, 16%). Anemia, raised serum creatinine, low eGFR values, low ejection fraction were significant predictors of non-favourable outcome in our study.CRS occurs in all age groups, more commonly in elderlies with a male preponderance. Prevalence of CRS-1 was higher followed by CRS-4. Prognosis was unfavourable in CRS-1, CRS-4 and CRS-5. Sepsis was predominant cause of death in patients with CRS-5 with hundred percent mortality during hospital stay. Risk factors like pre-existing renal impairment, anemia, reduced e GFR and low ejection fraction were significantly associated with worse outcomes. There is need for large scale population / community based studies to chart the prevalence of cardiorenal subtypes and prognosticate each individually.

Hypertension is one of the important contributing factors linked with both causation and development of kidney disease. It is a multifactorial, polygenic, and complex disorder due to interaction of several risk genes with environmental factors. The present study was aimed to explore genetic polymorphism in ACE-1 gene as a risk factor for CKD among hypertensive patients.Three hundred patients were enrolled in the study. Ninety were hypertensive patients with CKD taken as cases, whereas 210 hypertensive patients without CKD were taken as controls. Demographic data including age, sex, Body mass index (BMI), and other risk factors were also recorded. DNA was extracted from blood by salting out method. Genotyping of ACE gene was done by PCR technique. All the statistical analysis was done by using Epi Info and SPSS version 16 software (SPSS Inc., Chicago, IL).Mean age was higher in the control group (p 0.05). Variables among two groups were compared out of which age, BMI, hemoglobin (Hb) was found to be statistically significant whereas other variables like systolic blood pressure, triglyceride and low-density lipoprotein were not. Blood urea and serum creatinine levels were statistically significant in the two genotypes (p 0.05). Total and HDL cholesterol were statistically significant for DD genotype of ACE gene (OR = 1.42, 95% CI = 0.72-2.81). Similarly, the risk for CKD among hypertensive patients was also associated with D allele of ACE gene (OR = 1.25, 95% CI = 0.86-1.79).It is concluded that ACE-DD genotype may be a risk factor for the causation and development of chronic kidney failure among hypertensive patients.

Peripartum acute renal failure is an important complication related to pregnancy leading to significant morbidity and mortality. Emphysematous pyelonephritis (EPN) is a severe necrotizing infection of the renal parenchyma, with formation of gas within the collecting system, renal parenchyma, or perirenal tissues. EPN is common in persons with diabetes or urinary tract obstruction. Herein we report a case of bilateral emphysematous pyelonephritis in a postpartum lady who had no evidence of diabetes or urinary tract obstruction. Management of this condition has traditionally been aggressive, and surgery has been considered mandatory. Our patient was managed successfully with antibiotics and supportive measures alone.

Objectives The aim of this study is to compare the antiresorptive effect of hormone therapy and oral ibandronate in postmenopausal osteoporotic women by measuring bone mineral density (BMD) and degradation products of C-terminal telopeptide of type I collagen (CTX) using serum crosslaps ELISA. Study design The study is a randomized comparative trial. Methods About 60 women with age > 40 years, having either surgical or medical menopause with T- or Z-score below -2.5 SD were included in the study. They were randomized into two groups of 30 each; one group received conventional hormone therapy (group I) and the other group received ibandronate monthly (group II). The treatment was given for 6 months. Results The BMD increased from 0.894 g/cm2 to 0.933 g/cm2 ( p 2 to 0.934 g/cm2 ( p Conclusion Ibandronate can be used as a substitute to hormone therapy in women presenting with osteoporosis. Long-term studies are needed to authenticate the observation.

The study was undertaken to investigate the relative repellency of Pongamia pinnata and Azadirachta indica seed oils on vector mosquito, Aedes aegypti under laboratory conditions. The repellents were formulated into 3 groups: seed oils, their mixture and combination of seed oils with three carrier oils viz. olive, mustard and coconut oil. Different formulations of each oil were tested at the concentrations of 1% and 5% on human baits. Efficiency was assessed, based on the total protection time; biting rate and percent protection provided by each formulation. Results showed that 5% formulation of the Pongamia pinnata and Azadirachta indica seed oils, mixed in 1:1 ratio exhibited highest percentage repellency of 85%, protection time of 300 min and bite rate of 6%. 5% concentration of A. indica and P. pinnata seed oil in mustard oil base offered 86.36% and 85% protection respectively with total protection time of 230 and 240 min respectively. The study confirms that Azadirachta indica and Pongamia pinnata have mosquito-repellent potential. When mixed in different ratios or with some carrier oil their efficacy increases 2-fold in some cases. These formulations are very promising for topical use (5 hrs complete protection) and are comparable to the protection provided by advanced Odomos mosquito repellent cream available commercially and thus are recommended for field trial.

A retrospective analysis of eleven pregnancies complicated by isolated fetal congenital complete heart block (CCHB) in anti-SSA/Ro antibody positive women was carried out at a tertiary hospital in India to study the perinatal outcome. The mean gestational age at the time of detection of fetal CCHB was 24.5 ± 3.1weeks. Six mothers were asymptomatic; two had Sjogren's syndrome and three had systemic lupus erythematosus. Oral dexamethasone was given to all the patients after the diagnosis was made. There was one case of intrauterine death. Seven (63.6%) neonates needed a permanent pacemaker. There was no significant difference in the perinatal outcome in asymptomatic women with fetal CCHB and in women with connective tissue disorder and fetal CCHB. To conclude, fetal CCHB is associated with high morbidity but the presence of underlying connective disorder in the mother does not worsen the prognosis of the affected neonate.

The carboxyl-terminal hGH fragment, hGH 44–191 , displays diabetogenic activity. To understand whether this biological activity is mediated through somatogenic or lactogenic receptors, we investigated the ability of hGH 44–191 to bind both receptor classes. We found that hGH 44–191 could not compete with [ 125 I]hGH or [ 125 I]bGH for bovine liver somatogenic binding sites. Additionally, hGH 44–191 could not displace [ 125 I]hGH from the somatogenic receptor sites when human liver microsomes were used as the receptor source. In contrast, hGH 44–191 effectively competed with [ 125 I]hGH for lactogenic receptor sites of lactating mammary gland microsomes and of bovine liver microsomes. In summary, hGH 44–191 does not bind to somatogenic receptors but does not bind to lactogenic receptors. These data suggest that the biological actions of hGH 44–191 could be mediated through lactogenic receptors.

The present study examined whether (1) the cough associated with angiotensin converting enzyme inhibitor therapy is attenuated by oral intake of iron and anti-oxidants, and (2) nitric oxide (NO) has any role in this attenuation. Of the 100 patients under investigation, cough occurred in 28 of them with preponderance in females. All the 28 patients were followed up for six weeks: the first two weeks were the observation period and the remaining four weeks the experimentation period. After the observation period, 11 patients received a single oral dose of ferrous sulphate (200 mg), eight received vitamin E (200 mg, o.d.) and vitamin C (150 mg, o.d.) and nine were given placebo during the experimentation period. Cough scoring, serum NO and malondialdehyde (MDA) levels were determined during both the periods. While there were significant decreases in cough scores, NO and MDA levels between these two periods in the iron group, cough scores and MDA level decreased significantly in the anti-oxidant group. None of these parameters changed in the control group. NO level was found to be increased significantly in patients who developed cough ( n = 28) compared with those who did not cough ( n = 72). These results suggest that iron supplementation suppresses cough in patients on ACE-I therapy through its effect on NO generation.

Blood pressure usually increases in winter and decreases in summer i.e, shows seasonal variation. In a tropical country like India women often complain off prominent symptoms like dizziness, giddiness, fainting and weakness during summer months. The objective was to study the prevalence of above symptoms which are common during summer and its association with variation in blood pressure among normotensive healthy females aged 18-40 years.The present study was carried out on 132 women as a prospective observational study which included 2 home visits to the participants in the two different seasons in the months of May-June (summer) and December-January (winter) based on the data provided by the meteorological department of Government of India. Blood pressure and pulse rate (hemodynamic variables) was measured in these seasons and information was collected on the occurrence of the symptoms in these seasons.There was mean decrease of 11.07 +/- 10.29 mm of Hg in Systolic blood pressure6.79 +/-6.88 mm of Hg in diastolic blood pressure in summer as compared to winter. The symptoms in the form of weakness, dizziness and blackout which are generally perceived by women in this area to be due to low blood pressure were observed in 32.6% of the study subjects in summer compared with 2.3% in winter. The difference was statistically highly significant (p0.001). There was no significant difference between the mean value of electrolytes, creatinine and urea in the cases and the controls.Thus the seasonal variation in blood pressure rather than electrolytes abnormality may be responsible for these symptoms.

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.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.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).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.

A 25-year-old woman presented 6 months post-partum, complaining of multiple abdominal swellings progressively increasing in size and number, abdominal distension, anorexia, and a dull ache in the left flank for 5 months. There was no history of fever, cough, haematuria or other urinary complaints. The patient had delivered a premature male baby at seven and a half months gestation. The pregnancy and labour were uneventful and the patient was lactating at presentation. Examination revealed a markedly cachectic young woman with gross abdominal distension. Her pulse was 94 beats/min, regular, and blood pressure was 100/60 mmHg. Abdominal examination revealed a 10.0 × 12.5 cm large, irregular, firm, bimanually palpable mass in the left hypochondrium extending into the left lumbar and umbilical regions. Multiple hard, irregular masses, some confluent, others discrete, were palpated over all areas of the abdomen. A 6-cm firm, irregular hepatomegaly was present. The rest of the physical examination, including a per-vagina examination, was unremarkable. Contrast-enhanced computed tomography (CT) of the abdomen is shown in …

Castor and jequirity beans are uncommon causes of poisoning. The more common but less severe castor poisoning is well described, but jequirity bean (Abrus Precatorius) poisoning is rare. The toxicity is attributed to toxalbumins (ricin and abrin) that act by inhibiting protein synthesis. Their use as agents of biological warfare, mechanisms of action, and clinical features of poisoning are summarized.A 30-year-old previously healthy female presented with bloody diarrhea and deep coma following ingestion of 3-4 seeds of a plant called 'ratti.' Investigations, including an MRI brain scan, showed evidence of acute demyelinating encephalitis. The patient died three days later due to progressive central nervous system depression.This is a previously unreported manifestation of jequirity bean poisoning. Demyelination is immune-mediated, and Abrus is a well-known immuno-modulator and stimulator. A possible immunological pathogenic mechanism is hypothesized.

AmpC producing K. pneumoniae have been increasingly reported from India but epidemiological studies are lacking. In the present study, molecular epidemiology of extended-spectrum AmpC beta-lactamases (ESACs) producing clinical isolates of K. pneumoniae prevalent in our hospital was studied.Fifty-one non-repeat, consecutive, clinical isolates of K. pneumoniae producing AmpC enzymes, were subjected to whole cell protein profile analysis (SDS-PAGE) and ribotyping. The antimicrobial susceptibility was determined using standard disk diffusion technique. The isolates showing decreased susceptibility to cefoxitin (18 mm) or cefotetan (16 mm) were subjected to modified three- dimensional test for detection of AmpC enzyme.Six different types of protein profiles were observed. Ribotyping could further discriminate between the strains that were clustered by protein fingerprinting. Twelve different ribo-patterns were identified. Ribotyping was found to have a better Discriminatory Index (0.98) than that of SDS-PAGE (0.78). Of the 26 isolates that showed decreased susceptibility to cefoxitin and/or cefotetan 13 isolates were found to harbour AmpC enzyme.The study demonstrated the usefulness of SDS-PAGE whole cell protein profile analysis and ribotyping to identify the clonality of the ESACs isolates, the latter having a higher discriminatory power. The presence of ESACs isolates in the community as well as in hospital settings emphasizes the need for regular monitoring of antimicrobial resistance.

The Case: A 40-year-old woman presented to the emergency department with complaints of hemoptysis and epistaxis that had occurred off and on since childhood, as well as symptoms of dyspnea on exertion, fatigue and oligomennorrhea. She reported a similar history of recurrent epistaxis in her father

A thirty four year old female presented with upper and lower respiratory symptoms in the third trimester of pregnancy. After the delivery of a healthy baby, the symptoms progressed to involve multiple organ systems and eventually a diagnosis of limited Wegener's Granulomatosis (Carrington-Liebow syndrome) was made. The extremely rare combination of WG and pregnancy, especially the onset of disease in late pregnancy is discussed. The successful outcome of pregnancy even without treatment of WG is the highlight of the case.

Dengue fever (DF) and Dengue hemorrhagic fever (DHF) are widespread in Southeast Asia. An outbreak of DF/DHF in Delhi in 2003 started during September, reached its peak in October-November, and lasted until early December. This study describes the clinical and laboratory data of the 185 cases of DF/DHF admitted to Lok Nayak Hospital, New Delhi. The mean age of the patients was 26 +/- 10 years. Fever was present in all the cases with an average duration of fever being 4.5 +/- 1.2 days with headache (61.6%), backache, (57.8%), vomiting (50.8%) and abdominal pain (21%) being the other presenting complaints. Hemorrhagic manifestations in the form of a positive tourniquet test (21%), gum bleeding and epistaxis (40%), hematemesis (22%), skin rashes (20%) and melena (14%) were also observed. Hepatomegaly and splenomegaly were observed in 10% and 5% of cases, respectively. Laboratory investigations revealed thrombocytopenia (with a platelet count of100,000/microl) in about 61.39% of cases, Leukopenia (WBC3,000/mm2) and hemoconcentration (Hct20% of expected for age and sex) were found in 68% and 52% of the cases, respectively. The mortality rate was 2.7%. Despite widespread measures taken to control outbreaks of DF, it caused major outbreaks. More stringent measures in the form of vector control, improved sanitation and health education are needed to decrease morbidity, mortality and health care costs caused by a preventable disease.

Mesenchymal soft tissue masses are uncommon tumours of the chest. Myofibroblastoma is a recently described entity consisting of cells with origin from the myoepethelial cell, mostly seen as benign well-circumscribed neoplasms of the breast tissue. Though usually classified as a benign lesion, rarely it can be multifocal and prone to recurrence. We describe below the case of a 26-year-old female who presented with exertional dyspnoea and evidence of a massive mass lesion in the left hemithorax causing mediastinal displacement to the opposite side. On histological and immunophenotypic analysis, a diagnosis of the very rare thoracic myofibroblastoma was made. The incidence, salient features, pathological differential diagnoses and treatment are reviewed.

To study the incidence of clinical and subclinical optic nerve toxicity with ethambutol therapy in patients with tuberculosis and to evaluate the reversibility of its side effects after cessation of therapy. This prospective randomized controlled study included 60 newly diagnosed adult cases of tuberculosis, who were randomly assigned into two groups. The study group included 30 patients (60eyes) who received ethambutol as a part of their anti-tubercular treatment and the control group included 30 patients (60eyes) who did not receive ethambutol. The patients were examined on monthly basis. The visual parameters studied were best corrected visual acuity, pupillary reactions, optic disc changes, color vision, contrast sensitivity, pupil cycle time, visual field charting and visual evoked potential. Ethambutol was stopped in those patients in whom toxicity was detected and they were followed more frequently. Only one patient (3.3%) showed decrease in visual acuity, three patients (10%) developed visual field defects, two patients (6.7%) showed deterioration of contrast sensitivity, the pupil cycle time was prolonged in one eye and two patients (6.7%) showed abnormal visual evoked potential. During the therapy, all patients in the study group had normal pupillary reactions, fundus picture and color vision.Ethambutol induced ocular toxicity was seen in three patients (10%) in our study. The maximum visual recovery occurred in first six to eight weeks after stopping ethambutol. The visual recovery was complete in only one patient, but it was partial in two patients i.e. visual fields, contrast sensitivity and visual evoked potential remained abnormal.

A 55 year old female was admitted as a case of pyrexia of unknown origin (PUO) of 2 months duration. She had developed throat ache, progressive dysphagia for both solids and liquids, dry cough and retrosternal pain for one week. Examination revealed fever, tachycardia, tachypnoea and a soft tissue warm tender, erythematous, non-fluctuant swelling in lower anterior neck with chest findings suggestive of bilateral pleural effusion. Plain X-rays of the neck and chest strengthened the clinical suspicion of cellulitis of lower neck with bilateral pleural effusion. CT scan confirmed the radiologic findings and also revealed pericardial effusion and thickening; small mediastinal lymphadenopathy and mediastinitis. Patient responded to parenteral antibiotics (ceftriaxone and metronidazole) and hydrocortisone with complete resolution in 10 days.

Human immunodeficiency virus (HIV) infection is associated with a profound dysregulation of the immune system and alterations in the cytokine profile. Tuberculosis, a common opportunistic infection in HIV positive patients, leads to further immune suppression and a faster progression of the disease. This study was conducted to assess and compare the cytokine profiles in HIV positive subjects with and without pulmonary tuberculosis.Twenty HIV positive patients and 20 controls were evaluated after being divided into four groups of 10 each--group 1--HIV positive patients without tuberculosis, group 2--HIV positive patients with pulmonary tuberculosis, group 3--healthy adults and group 4--HIV negative patients with pulmonary tuberculosis. After clinical evaluation, the CD4 cell counts and the cytokine profiles--interleukins (IL)-2, 4, 6, 10, 12, interferon gamma (IFN gamma) and tumour necrosis factor alpha (TNF alpha) were studied in all the subjects at the start and after three months of antituberculosis therapy.the CD4 cell counts were significantly lower in groups 1 and 2 compared to groups 3 (p0.01) and the counts in group 2 were significantly lower than in group 1 in both at baseline (p = 0.0076) and at three months (p = 0.089). The levels of the type 1 cytokines (IL-2, IL-12 and IFN gamma were significantly lower in patients in groups 1 and 2 compared to group 3 (p0.001 for both). The levels in group 2 were lower than in group 1 (p0.001). The type 2 cytokines (IL-4, IL-6, IL-10 and TNF alpha) were higher in group 1 and 2 compared to group 3, though statistically significant for IL-6 in group 1 (p0.05) and for IL-4, IL-6 and TNF alpha in group 2. A highly significant (p0.0001) positive correlation between CD4 cell counts and type 1 cytokines and a highly significant (p0.0001) negative correlation between CD4 cell counts and type 2 cytokines was observed.A decline in the type 1 and a rise in type 2 cytokines was observed in HIV infection. Patients in group 2 had the lowest CD4 cell counts, lowest levels of type 1 cytokines and highest levels of type 2 cytokines denoting maximum immunosuppression.

Bladder exstrophy is a rare congenital anomaly, with incidence varying from 1:30,000–1:50,000 live births; involvement of females being rarer (Giron et al. 2011). It involves maldevelopment of the ...

Present communication deals with 76 ethnomedicinal plants being used traditionally in Karnataka, India. These plants are reported to have 78 less known ethnomedicinal uses for curing various skin diseases, cuts, stomach disorders, gynaecological complaints and snakebites.

Cough is an important side effect of Angiotensin Converting Enzyme Inhibitor (ACEI) therapy. The incidence of cough was investigated in a prospective 8 week study in 250 hypertensive patients receiving ACEI alone or in combination with other agents. Enalapril (5-20 mg/day), Lisinopril (5-20 mg/day), Captopril (25-75 mg/day) or Ramipril (5-15 mg/day) was prescribed to patients, who were followed up at weekly visits. Cough developed in 73 of the 250 patients i.e. an incidence of 29.2%. Females had a higher incidence of cough as compared to males--37.9% versus 15.5% (p0.001) and there was no significant difference in the cough incidence in the various age groups. A dry, non-productive cough developed in all patients within 4 weeks of ACEI initiation. Increased nocturnal intensity of cough was reported by 79.4% patients. Cough incidence was 34.4%, 24.3% and 18.1% in patients on Enalapril, Ramipril and Lisinopril, respectively. Cough was not dose related and was not related to smoking. There was no statistically significant difference among patients on ACEI alone or in combination with beta blockers, calcium channel blockers or diuretics. Of the 18 patients with ACEI induced cough who received Indomethacin, 50 mg bid, 8 reported complete cure and cough was reduced in intensity in the remaining ten.

The Senior-Loken syndrome, also called Hereditary Renal Retinal Dystrophy is a rare disorder that combines a juvenile nephronophthisis-like disease with tapetoretinal degeneration. We are reporting a family in which two, possibly three siblings are affected by this disorder. In addition to these two documented components of the disease, our patients also have unusual manifestations: short stature; skeletal abnormalities in the form of kyphoscoliosis, short metacarpals; and cutis laxa-unreported so far.

Left ventricular hypertrophy (LVH) has been identified as an independent risk factor for mortality in patients with chronic renal failure (CRF) and anemia has been proposed to contribute to LVH. The cardiovascular and hemodynamic effects of correction of anemia with recombinant human erythropoietin (rHU EPO) was assessed in a 12 week prospective study in patients with CRF.Biochemical parameters and echocardiography were studied at the start and after three months therapy with EPO in 24 patients with CRF--11 predialysis (Group I) and 13 dialysis (Group II).The mean haemoglobin (Hb)--g/dl increased significantly from 7.5 +/- 1.0 to 10.1 +/- 1.1 in group I and from 6.7 +/- 0.6 to 9.4 +/- 0.8 in group II (p0.05) on EPO therapy. The left ventricular mass index (LVMi)--g/m2 reduced significantly from 185.6 +/- 44.6 to 158.3 +/- 4.1 in group I and from 158.0 +/- 26.9 to 131.6 +/- 22.1 in group II (p0.05 in both). The interventricular septal thickness (IVST) also showed a significant decline in both groups, 1.17 +/- 0.06 to 1.14 +/- 0.05 (group I) and 1.09 +/- 0.25 to 1.01 +/- 0.21 (group II), p0.05 in both. The thickness of the left ventricular posterior wall remained unchanged. The left ventricular end diastolic and systolic diameters (LVEDD and LVESD) significantly reduced from their baseline values in both the groups (p0.05). The diastolic filling parameters across the mitral valve remained unchanged in both the groups. The cardiac index (CI)--L/min/m2 decreased from 3.53 +/- 0.3 to 3.03 +/- 0.27 in group I and from 3.31 +/- 0.64 to 2.80 +/- 0.60 in group II (p0.05) and the total peripheral resistance (TPR)--dynes/cm5/sec increased from 1567 +/- 164.8 to 1883 +/- 190.7 in group I and from 1618 +/- 375.7 to 2004 +/- 437.3 in group II. The differences in all the parameters at the start and after 3 months of EPO were comparable in groups I and II. The mean arterial pressure (MAP) changed insignificantly in both the groups.To conclude, this study has shown that the decrease in LVMi with EPO reflects the role of anemia in the genesis of LVH and that the correction of anemia with EPO in CRF results in regression of LVMi and has a favourable effect on cardiovascular hemodynamics.

A major outbreak of epidemic dropsy occurred in Delhi, India, in August-September 1998, due to the consumption of contaminated mustard oil.The clinical data of 212 adult patients of epidemic dropsy who presented to our hospital is analysed.Pitting pedal oedema (100%), skin erythema (75%), limb tenderness (63%), diarrhea (51%) and hepatomegaly (34%) were the prominent clinical manifestations observed in the patients. Superficial retinal haemorrhages and retinal venous dilatation was observed on fundus examination and 9% of patients developed an open angle glaucoma over a three month follow up period. Cardiac failure was present in 14% of patients. Most patients had mild disease which responded to cessation of mustard oil consumption, bed rest, diuretics and antioxidants. There were six deaths, all of whom had intractable cardiac failure. A unique feature of this outbreak was the documentation of acute renal failure in three patients, a phenomenon never described previously.Strict law enforcement to prevent the contamination of edible oils is essential to avoid the occurrence of future similar outbreaks.

The use of erythropoietin (EPO) for the amelioration of anemia has dramatically changed the quality of life of the patients with chronic renal failure (CRF). The efficacy of a low dose EPO therapy was assessed in the prospective 6 week trial.Assessment of hematological parameters and iron stores was done in 40 patients of CRF: Group A--20 patients of CRF receiving 40 U/kg EPO biweekly for 6 weeks and Group B--20 patients of CRF not receiving EPO. The parameters were studied at the start and at 2, 4 and 6 weeks of the study.A statistically significant rise in mean haemoglobin levels (7.27 +/- 1.26 g/dl to 8.60 +/- 1.66 g/dl); mean packed cell volume (21.4 +/- 4.04% to 25.4 +/- 6.54%) and mean reticulocyte count (1.28 +/- 0.4% to 2.14 +/- 0.86%) was observed on EPO therapy. Patients on EPO developed a significant decline in serum iron, serum ferritin levels, bone marrow iron stores; and a hypochromic-microcytic picture on the peripheral blood film suggestive of iron deficiency. Iron deficiency at the start, chronic infections like tuberculosis and inadequate haemodialysis were identified as causes of hyporesponsiveness to EPO therapy. Low dose EPO therapy was not associated with any major adverse effects.Low dose EPO (40 U/kg, biweekly) therapy is safe and effective in the management of anaemia of CRF.

Cell mediated immunity (CMI), cytokines and humoral immunity have been implicated in the pathogenesis of invasive amoebiasis.The role of cytokines--tumour necrosis factor-alpha (TNF-alpha) and interleukin 2 (IL-2) in blood and pus aspirate was studied in 20 patients of amoebic liver abscess (ALA), before and after treatment and 10 controls.The mean TNF-alpha levels (pg/ml) in the controls and before treatment in the patients in serum and pus were 24.3 +/- 11.6, 28 +/- 14.5 and 161.2 +/- 81.3 (p0.002) respectively. The mean IL-2 levels (pg/ml) in the controls, serum and pus aspirate in the patients prior to treatment were 10.3 +/- 8.5, 39.2 +/- 26.1 and 117.0 +/- 65.9 respectively. The levels in the patients after therapy, increased to 47 +/- 25.7 (p0.001) and 134 +/- 59.4 (p0.01).The higher levels of TNF-alpha and IL-2 in the pus aspirate compared to blood pre treatment, supports the role of locally released cytokines in the target organ i.e. liver in amoebiasis. The rise in values observed after therapy are indicative of increased macrophage activity due to CMI occurring late in the course of the disease which may contribute to disease limitation and localisation in amoebiasis. The study suggests that locally released cytokines play an important role in the pathogenesis of ALA.

The aim of the study was to assess the efficacy, tolerability and chondroprotection afforded by nimesulide, a selective cyclooxygenase-2 inhibitor and piroxicam in a randomised, double blind, controlled clinical trial in 90 patients suffering from osteoarthritis of the knee joint. A significant improvement in the osteoarthritis severity index at 2 weeks (p0.01) and an improvement in physicians assessment of global arthritic condition at 4 weeks (p0.01) was seen with both the treatments. A significant decrease in articular index of joint tenderness (p0.05) at 8 weeks and in self assessment of handicap at 4 weeks (p0.05), in comparison to baseline, was observed only in patients receiving nimesulide. Rescue therapy was required by a greater percentage of patients being administered piroxicam. Functional capacity improved in 64% of the patients on nimesulide and 74.5% of the patients receiving piroxicam. Adverse effects were observed in 6 patients on nimesulide and 9 patients receiving piroxicam. No significant difference was found in any of the efficacy and tolerability parameters between the two treatment groups. Magnetic resonance imaging evaluation of the knee joint of 10 patients showed no significant change in the articular cartilage and associated joint structures after 6 months of therapy with both the treatments. The results show that nimesulide and piroxicam are comparable in efficacy and tolerability in patients suffering from osteoarthritis.

A major outbreak of dengue hemorrhagic fever (DHF) affected more than 10,000 people in Delhi and neighboring areas in 1996. The outbreak started in September, peaked in October to November and lasted till early December. The clinical and laboratory data of 515 adult patients admitted to Lok Nayak Hospital, New Delhi were reviewed. Fever (100%), myalgias and malaise (96%), abdominal pain (10.2%) and vomiting (8.7%) were the prominent presenting features. Hemorrhagic manifestations were seen in all patients- a positive tourniquet test (21.2%), scattered petechial rash (23.07%), confluent rash (2.7%), epistaxis (38.4%), gum bleeds (28.06%) and hematemesis (22.86%) being the major bleeding manifestations. Hepatomegaly was observed in 96% of the patients. Laboratory investigations revealed thrombocytopenia, hemoconcentration and leukopenia. Serological confirmation with a microcapture ELISA technic was done in 143/515 patients. The mortality rate was 6.6% and, multiple bleeding manifestations, severe thrombocytopenia, hypoproteinemia and dengue shock syndrome (DSS) were associated with a higher mortality.

A new ligand N-salicyloyl-N'-(p-hydroxybenzthioyl) hydrazine (H2STPH) and its Cu(II) complex [Cu(SPTH)] were prepared and characterized by analytical and physicochemical studies. In vivo antitumor activity of [Cu(STPH)] has been tested against breast tumor in C3H/J strain mice and in vitro on P-815 (murine mastocytoma) and K-562 (human erythroleukemia) cells. LD50 values were estimated at a dose level of 100 mg/kg body weight and a light microscopic study also carried out.

An enzyme immunosorbent assay (ELISA) was evaluated as a serodiagnostic test in patients with active tuberculosis (Group I), clinically suspected pulmonary tuberculosis (Group II) and pulmonary diseases other than tuberculosis and normal healthy subjects (Group III). and compared with culture and sputum smear examination results. ELISA was found to have a sensitivity of 77.5% and a specificity of 87.5%. Sputum smear had a sensitivity of 65% and specificity of 100%. In patients clinically suspected to have pulmonary tuberculosis ELISA had a sensitivity of 60%. Thus ELISA using A60 antigen can facilitate the diagnosis of tuberculosis in patients with active as well as suspected pulmonary tuberculosis and can provide results within hours of receipt of samples.

In the presence of iron, dihydroartemisinin forms free radicals and causes cell death. Since most cancer cells have high rates of iron intake, dihydroartemisinin would have selective cytotoxic effect on cancer cells. The present experiment was designed to study the effect of dihydroartemisinin and ferrous sulfate on the growth of implanted fibrosarcoma in the rat. We found that the growth rate of the tumor was significantly retarded by daily oral administration of ferrous sulfate followed by dihydroartemisinin. No significant tumor growth retardation effect was observed in rats treated with either dihydroartemisinin or ferrous sulfate alone. The drug treatment did not significantly affect body weight compared with untreated tumor-implanted animals and no apparent toxic effect was observed after drug treatment. An artemisinin analog-ferrous salt combination may provide a novel approach for cancer therapy.