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OBJECTIVE Despite the availability of effective medications, only a minority of asthma patients achieve guideline defined asthma control. Treatment success depends on patient concurrence to the prescribed drug and adherence to treatment. It is therefore crucial to identify the patient preferences as well as attitudes towards asthma medications. Omalizumab is recommended as a preferred option in step 5 of asthma therapy. There have been few studies to address patient perspectives on omalizumab therapy in India. METHODS This was a retrospective study. Patients with inadequate asthma control were considered for the study. Systematic evaluation was done to identify and correct modifiable factors that can worsen asthma control. Patients with persisting poor asthma control who were deemed suitable to receive this agent were evaluated with their attitudes toward acceptance or refusal and the reasons for opting out were noted. The patients who received omalizumab were followed up to determine the results of treatment and duration of adherence to therapy. RESULTS Thirty-five patients out of 51 patients chose to avoid this drug. The reasons for opting out included erroneous perception of optimal asthma control, cost of therapy, and concern about adverse effects. Patients took omalizumab for a median duration of 6 months. Improved asthma control and decreased frequency of exacerbation was noted in all patients which persisted during the 6-month follow-up. CONCLUSIONS The majority of patients needing step 5 therapy opt out of omalizumab. Cost of drug, duration of therapy and erroneous perception of good asthma control account for refusing treatment. Omalizumab affords excellent clinical benefits to patients who receive it, and the benefits extend beyond the duration of therapy.

Primary malignant melanoma of the vagina accounts for less than 0.3% of all melanomas and approximately 4% of vaginal malignancies. We present a case of a 61-year-old female who presented with complaints of difficulty in urination and a polyp arising from the vagina. Local examination showed a polyp arising from the lateral vaginal wall and a hymenal tag. Histopathological examination of the polyp showed a neoplasm simulating a leomorphic sarcoma. The hymenal tag showed classical features of malignant melanoma. Immunohistochemistry with S100 and HMB45 confirmed malignant melanoma in the vaginal polyp. We report this case, on account of its rarity and unusual phenotypic profile, which may lead to a delayed or alternate diagnosis. Primary malignant melanoma of the vagina needs early accurate diagnosis and management due to its aggressive nature. Keywords: Vaginal melanoma, Mucosal melanoma, Vaginal polyp, Sarcomatous polyp.

To determine whether additional dedicated observations by a doctor would increase the pickup rate of phlebitis and related complications due to intravenous cannulation. Also, to identify the common demographic and clinical factors predisposing to phlebitis in children. This prospective study was conducted from January 2019 through December 2019. A total of 184 children with 341 cannulations were enrolled. The authors added dedicated inspection of cannula by the physician during rounds in attempt to increase the detection of phlebitis. The difference in detection rates of thrombophlebitis by physician and routine observation along with the demographic and clinical variables contributing to thrombophlebitis in hospitalized children were studied. Total incidence of thrombophlebitis was 35/341 (10.3%), which included 2 extravasations. Nineteen events (55%) were picked up by routine nursing observations and an additional 16 (45%) by the physician. Among the factors contributing to phlebitis, maternal education status

Background In response to the WHO recommended measures of physical and social distancing to mitigate person-to-person transmission, most countries decided to close schools as part of a physical distancing policy to slow transmission of COVID-19 and to ease the burden on health systems. Schools were closed in more than 160 countries by mid-July 2020 due to the COVID-19 pandemic. Public health measures taken to prevent the spread of the pandemic can potentially impact the mental health of children. Not much is known about the long-term impact of large-scale disease outbreaks on the mental health of children and adolescents. Objectives To assess the prevalence and risk factors of childhood depression during the Covid-19 lock-down among school children. Methods After 100 days of lock-down, a voluntary, anonymous survey questionnaire was sent by WhatsApp to parents of school-aged children (5–16 years) in Chennai. The Short Mood and Feelings questionnaire was employed as an objective screening tool to assess depression, with a score of 12 used as the cut-off which is recommended by the Child Outcomes Research Consortium, United Kingdom. All data were analyzed using Statistical Package for Social Science (SPSS, version 17) for Microsoft Windows. A chi-squared test was used for comparison between two attributes with OR 95% CI. Multiple logistic regression was used. A two-sided p value Results There were 874 responses. Our survey revealed the incidence of childhood depression to be 13.7%, indicating that children are likely to be experiencing increasing depression exacerbated by the pandemic and the lock-down. Boys were less likely to be depressed than girls (OR 0.495, P value 0.000). Eleven- to 16-year-olds were more likely to be depressed than 5- to 10-year-old children (OR 1.519, P 0.035). Children who had more than 4 hours online education were more likely to have depression (OR 1.757, P= 0.037). Children who used a cell phone for online classes were more likely to have depression compared to other devices, such as tabs or laptops (OR 2.142, P 0.000). Children who slept less than 8 hours a day were more likely to have depression (OR 2.441, P 0.000). Children who either did not sleep in the afternoon or slept less than 1 hour were less likely to have depression (OR 0.522, P 0.010). Children who were interacting with family over 1 hour per day were less likely to have depression (OR 2.985, P 0.000). Conclusions Overzealous online education, lack of adequate sleep and failure to spend quality time with family and can negatively impact the mental health of school children. Public health policy makers and health care professionals need to acknowledge that pandemics (especially when associated with lock-down) can potentially negatively impact the psychological well-being of school-age children. In the event of similar future pandemics, strategies need to be in place to safeguard the psychological well-being of individuals by offering them timely and appropriate psychological support, as well as taking the appropriate steps in the effective management of those already affected psychologically.

Trastuzumab improves survival in patients with HER2+ early breast cancer. However, cardiotoxicity remains a concern, particularly in the curative setting, and there are limited data on its incidence outside of clinical trials. We retrospectively evaluated the cardiotoxicity rates [left ventricular ejection fraction (LVEF) decline, congestive heart failure (CHF), cardiac death or trastuzumab discontinuation] and assessed the performance of a proposed model to predict cardiotoxicity in routine clinical practice. Patients receiving curative trastuzumab between 2011 and 2018 were identified. Demographics, treatments, assessments and toxicities were recorded. Fisher’s exact test, Chi-squared and logistic regression were used. 931 patients were included in the analysis. Median age was 54 years (range 24–83) and Charlson comorbidity index 0 (0–6), with 195 patients (20.9%) aged 65 or older. 228 (24.5%) were smokers. Anthracyclines were given in 608 (65.3%). Median number of trastuzumab doses was 18 (1–18). The HFA-ICOS cardiovascular risk was low in 401 patients (43.1%), medium in 454 (48.8%), high in 70 (7.5%) and very high in 6 (0.6%). Overall, 155 (16.6%) patients experienced cardiotoxicity: LVEF decline ≥ 10% in 141 (15.1%), falling below 50% in 55 (5.9%), CHF NYHA class II in 42 (4.5%) and class III–IV in 5 (0.5%) and discontinuation due to cardiac reasons in 35 (3.8%). No deaths were observed. Cardiotoxicity rates increased with HFA-ICOS score (14.0% low, 16.7% medium, 30.3% high/very high; p = 0.002). Cardiotoxicity was relatively common (16.6%), but symptomatic heart failure on trastuzumab was rare in our cohort. The HFA-ICOS score identifies patients at high risk of cardiotoxicity.

The coronavirus disease 2019 (COVID-19) pandemic is a global health care emergency. Although reverse-transcription polymerase chain reaction testing is the reference standard method to identify patients with COVID-19 infection, chest radiography and CT play a vital role in the detection and management of these patients. Prediction models for COVID-19 imaging are rapidly being developed to support medical decision making. However, inadequate availability of a diverse annotated data set has limited the performance and generalizability of existing models. To address this unmet need, the RSNA and Society of Thoracic Radiology collaborated to develop the RSNA International COVID-19 Open Radiology Database (RICORD). This database is the first multi-institutional, multinational, expert-annotated COVID-19 imaging data set. It is made freely available to the machine learning community as a research and educational resource for COVID-19 chest imaging. Pixel-level volumetric segmentation with clinical annotations was performed by thoracic radiology subspecialists for all COVID-19-positive thoracic CT scans. The labeling schema was coordinated with other international consensus panels and COVID-19 data annotation efforts, the European Society of Medical Imaging Informatics, the American College of Radiology, and the American Association of Physicists in Medicine. Study-level COVID-19 classification labels for chest radiographs were annotated by three radiologists, with majority vote adjudication by board-certified radiologists. RICORD consists of 240 thoracic CT scans and 1000 chest radiographs contributed from four international sites. It is anticipated that RICORD will ideally lead to prediction models that can demonstrate sustained performance across populations and health care systems., NA

Introduction: The deformity and imbalance in an osteoarthritic knee undergoing Total Knee Arthroplasty (TKA) are the result of a combination of bony and soft tissue changes locally. Proper and ideal balancing of ligaments is considered essential to the success of a TKA. There are numerous techniques to achieve soft tissue balance in varus knee. More recently, Medial Tibial Reduction Osteotomy (MTRO) has been described as an adjuvant to soft tissue release. Limited data exists on the outcomes of patients requiring a MTRO. There are not many Indian studies available regarding the radiographic and clinical outcomes of medial reduction osteotomy in severe varus deformity in TKA. Aim: To find out the radiological and functional outcome of MTRO for severe varus deformity in patients undergoing TKA. Materials and Methods: This study was Prospective Cohort study conducted at the Department of Orthopaedics, Rajagiri Hospital, Chunangamveli, Aluva, Kerala from December 2018 to November 2019. Twenty patients 15 females and 5 males (30 knees), in the age group 55-80 years with osteoarthritis of knee with severe varus deformity, were enrolled in the study. Preoperative and postoperative standing leg Antero-posterior radiographs were taken for all patients and hip- knee- ankle angle was measured and amount of deformity correction was calculated. Postoperatively, radiographs were taken on the 5th day and 3rd month. Knee society scores were also recorded preoperatively and on the 5th postoperative day, postoperative visits on 6 weeks, 3 months and clinical outcome was assessed. The statistical analysis was performed by SPSS version 25 using Analysis of Variance(ANOVA) and Wilcoxon Signed Rank test. Results: The median knee score improved from 47±9 to 93±3 postoperatively. Similarly, median function score improved from 50±5 to 80±0. The improvement in function score and knee score were statistically significant (p-value 0.001). The correction of varus between preoperative, postoperative (p-value 0.001) day 5 & 3 months postoperatively was statistically significant. No patient required a release of the superficial Medial Collateral Ligament (MCL). The MTRO was associated with statistically significantly improved Knee Society scores and varus deformity correction. Conclusion: In patients with fixed varus deformity of the knee, the MTRO is found to be safe and adequate to achieve coronal alignment.

Background Previous studies regarding survival in patients with splanchnic vein thrombosis (SVT) are limited. This study measured overall survival in a large cohort of SVTs through linkage to population‐based data. Methods and Results Using a previously derived text‐search algorithm, we screened the reports of all abdominal ultrasound and contrast‐enhanced computed tomography studies at The Ottawa Hospital over 14 years. Screen‐positive reports were manually reviewed by at least 2 authors to identify definite SVT cases by consensus. Images of uncertain studies were independently reviewed by 2 radiologists. One thousand five hundred sixty‐one adults with SVT (annual incidence ranging from 2.8 to 5.9 cases/10 000 patients) were linked with population‐based data sets to measure the presence of concomitant cancer and survival status. Thrombosis involved multiple veins in 314 patients (20.1%), most commonly the portal vein (n=1410, 90.3%). Compared with an age‐sex‐year matched population, patients with SVT had significantly reduced survival in particular with local cancer (adjusted relative excess risk for recent cases 12.0 [95% CI, 9.8–14.6] and for remote cases 9.7 [7.7–12.2]), distant cancer (relative excess risk for recent cases 5.7 [4.5–7.3] and for remote cases 5.4 [4.4–6.6]), cirrhosis (relative excess risk 8.2 [5.3–12.7]), and previous venous thromboembolism (relative excess risk 3.8 [2.4–6.0]). One hundred fifty (23.9%) of patients >65 years of age were anticoagulated within 1 month of diagnosis. Conclusions SVT is more common than expected. Most patients have cancer and the portal vein is by far the most common vein involved. Compared with the general population, patients with SVT had significantly reduced survival, particularly in patients with concomitant cancer, cirrhosis, and previous venous thromboembolic disease. Most elderly patients did not receive anticoagulant therapy.

Introduction: Public health measures taken to prevent the spread of the COVID-19 pandemic can potentially impact the mental health of children.Aims: To assess the prevalence and risk factors of childhood depression during the Covid-19 lock-down.Methods: After 100 days of lock-down, a survey questionnaire was sent by WhatsApp to parents of school-aged children (5-16 years) in Chennai. The Short Mood and Feelings questionnaire was employed as an objective screening tool to assess depression, with a score of 12 used as the cut-off.Results: There were 874 responses. The incidence of childhood depression was 13.7%. Boys were less likely to be depressed than girls. Eleven- to 16-year-olds were more likely to be depressed than 5- to 10-year-old children. Children who had more than 4 hours online education had a higher likelihood of depression. Children who used a cell phone for online classes had a higher likelihood of depression compared to other devices, such as tabs or laptops. Children who slept less than 8 hours a day had a higher likelihood of depression. Children who either did not sleep in the afternoon or slept less than 1 hour had a lower likelihood of depression. Children who were interacting with family over 1 hour per day had a lower likelihood of depression.Conclusions: Overzealous online education, lack of adequate sleep and failure to spend quality time with the family can negatively impact the mental health of children. The impact of Covid-19 on the emotional health of children should be addressed by public policy makers and health care professionals.

Tympanoplasty is a surgical procedure performed for the closure of tympanic membrane perforation. The present study was conducted to compare the outcomes of a newer technique of cartilage tympanoplasty which the author has named as half disc cartilage tympanoplasty and temporalis fascia tympanoplasty in the following areas—the improvement in hearing, frequency specific improvement in hearing, graft uptake rate. Retrospective study was conducted in the Department of Otorhinolaryngology Rajagiri Hospital from February 2018 to February 2020. 40 patients with moderate central, subtotal and anterior perforation were included in the study. 20 patients (group A) underwent tympanoplasty with temporalis fascia graft and 20 patients (group B) underwent tympanoplasty with temporalis fascia and cymba concha with perichondrium as the support in the anterior half. Both groups were compared for the improvement in hearing and frequency specific improvement in hearing. Follow up period for the study was 6 months. Chi square and t tests were used to assess association and as tests of significance. In our present study hearing improvement following half disc cartilage tympanoplasty was better than temporalis fascia tympanoplasty. In post half disc cartilage tympanoplasty and post temporalis fascia tympanoplasty hearing gain was maximum in low frequencies. Half disc cartilage tympanoplasty is superior to temporalis fascia tympanoplasty in terms of hearing gain. Low frequency hearing shows significant improvement following tympanoplasty.

This retrospective analysis aimed to evaluate the clinicopathological characteristics of primary mucinous tumors of the ovary (MOT) treated at a tertiary care center. Demographic, clinicopathological, treatment and follow-up details of all patients with primary MOT treated from June 2015 till August 2019 were extracted from institutional cancer registry and Electronic Medical Records, after obtaining necessary clearance from institutional ethical committee, and institutional review board. The details obtained were tabulated and analyzed. Thirty-one patients were identified to have primary MOT: 20 cystadenomas, 10 carcinomas (mOC) and one borderline (mBOT). MOT was frequently noted between the fourth to sixth decades. Abdominal distension was the most common symptom at presentation. In total, 70% of cystadenomas were less than 15 cm, while 90% of mOC were 15 cm and above. In total, 95% cystadenomas were unilateral, while all cases of mBOT and mOC were unilateral. mOC showed elevated CA 125 in 42.86% cases, elevated CEA in 42.86% cases and elevated CA 19–9 in 75% cases. Imaging showed 30% of mOC as benign cysts and 42.1% of cystadenomas as complex cyst. Frozen section correctly diagnosed cystadenomas and mBOT, and two mOC were underdiagnosed as borderline. All had upfront surgery. Of cystadenomas, 11 underwent salpingoovariotomy, and nine had hysterectomy and salpingoovariotomy. All the mOC and mBOT underwent staging laparotomy. Three cases of mOC had a fertility preserving approach. No cases had positive lymph nodes, and appendix showed normal histology. In total, 40% were stage 1a, 30% 1C1 and 30% IC3. Two patients received postoperative chemotherapy. Differentiation between benign MOT and mOC is crucial. A multidisciplinary approach, involving clinician, radiologist and pathologist, helps in clinching the diagnosis. mOC present at a younger age and fertility-sparing procedures are reasonable options in early-stage MOT.

Purpose: The purpose of this study is to assess the complication rate of percutaneous image-guided biopsy of the spleen at our institution and to evaluate for variables associated with complication rate. Methods: This is a Research Ethics Board approved retrospective study of consecutive patients who underwent image-guided biopsy of the spleen at our institution from January 2010 to November 2019. Complications, imaging findings, and pathologic diagnosis were reviewed. Complications (major and minor) were classified per Society of Interventional Radiology Guidelines, and complication rate was calculated. Logistic regression was applied to determine factors associated with complications. Diagnostic yield was calculated. Results: In all, 55 patients (28 female) underwent splenic biopsy using ultrasound guidance. The most common indication was possible lymphoma in 41 (71.7%) patients followed by query metastasis 18 (31.5%) patients. Core biopsies (18 g/20 g) were done in 53 (92%) cases, and fine-needle aspiration (22 g) was performed in 4 (8%). The median number of samples collected was 4 (range: 2-9). The results were diagnostic in 54 cases (94.7%, 95% confidence interval [CI]: 88.7-100.0). There were 12 (21%, 95% CI: 10.1-31.9) patients with minor complications and 2 (3.5%, 95% CI: 0.0-8.4) with major complications (2 splenic bleeds requiring embolization, no splenectomy, or deaths). No variables (needle size, lesion size, and number of passes) were associated with complication rate. Conclusion: Percutaneous image-guided biopsy of the spleen at a single tertiary care institution demonstrates major complication rate comparable to that in the literature with no variables associated with complication rate; there were no cases of splenectomy or death.

Antimicrobial stewardship is a key strategy to facilitate judicious antimicrobial use. Software that can amalgamate prescribing and microbiology information in near real-time reporting and track antimicrobial resistance patterns aids timely interventions. This article examines the impact of a clinical surveillance software used to identify patients for prospective audit and feedback rounds by an antimicrobial stewardship team on antibiotic utilization, patient outcomes and workload efficiencies at an acute care community hospital. Results from a general internal medicine unit show statistically significant reductions in the use of broad-spectrum antibiotics and antibiotic expenditures, with no untoward changes in key clinical and patient safety outcomes.

Background: The recent COVID-19 pandemic has highlighted the relevance of following hygiene practices across all sectors of healthcare workers. Disparities in the correct practices among clinical and para clinical cadres of HCWs predispose to increased risk of infection. A survey was conducted to assess the hand and respiratory hygiene practices across the hospital.Methods: A cross sectional survey was conducted through a self-administered questionnaire across an online platform with questions on hand hygiene, mask and surface contamination related practices. Staff were grouped as clinical and para clinical for comparison of these practices.Results: Among the 501 respondents, 83.4% were females with a mean age of 30.78±8.48 years. Nursing staff were the majority (57.88%) followed by nonclinical and para clinical staff (20.77%). Of the study population, 96.6% performed hand wash and 97.2% refrained from giving handshakes in the previous hour. Over 60% maintained proper face mask practices. Undoing the lower tie of the mask first, was answered by 76.67% while 7.2% felt the sequence was irrelevant. Touching common surfaces were avoided by 46.3% of them, while 95% immersed their hospital attire in soap and water for 15 minutes. It was seen that a greater proportion of clinical staff had better practices when compared to para clinical and the difference statistically significant. There was no significant variation of practices with age.Conclusions: Focussed monitoring and motivation can help in improving hygiene practices among all cadres of HCWs.

Introduction: We aimed to report the clinically significant prostate cancer (PCa) detection rate in men undergoing magnetic resonance imaging-transrectal ultrasound (MRI-TRUS)-cognitive fusion (CF) targeted biopsies stratified by the Prostate Imaging and Data Reporting System (PI-RADS) version 2 (v2) scores. Methods: With a quality assurance waiver from the institutional review board, we identified a cohort of men who underwent MRITRUS- CF and synchronous template biopsy from 2015–2017. MRI (PI-RADS v2 score, lesion size, lesion location [peripheral or transition zone (PZ/TZ)]), and CF-TRUS biopsy (operator experience, TRUS visibility, and number of biopsies) features were extracted. The primary outcome was diagnosis of clinically significant (Gleason score ≥3+4=7 or International Society of Urological Pathology [ISUP] grade group ≥2) PCa. Results: During the study period, 131 men (with 142 PI-RADS v2 score ≥3 lesions) met inclusion criteria; 98 men had previously negative template biopsy and 33 were on active surveillance for previously detected low-grade PCa. In total, 41.9% (55/131) men had clinically significant PCa — 17.6% (23/131) detected on targeted biopsy only, 8.4% (11/131) on template biopsy only, and 16.0% (21/131) on both targeted and template biopsy. Clinically significant PCa detection stratified by PI-RADS v2 scores were: 11.1% (3/27) for score 3 (indeterminate), 42.9% (24/56) for score 4 (significant cancer likely), and 35.6% (21/59) for score 5 (significant cancer very likely). Clinically significant PCa detection rates in targeted biopsies were better among PZ (41.8% [33/79]) compared to TZ (23.8% [15/63]) lesions (p=0.025) in TRUS-visible lesions (p=0.033) and in the most experienced radiologists (p=0.05), with no difference by lesion size or number of additional core biopsies performed (all p>0.05). Conclusions: CF-MRI-TRUS-guided targeted biopsy yielded substantially lower rates of clinically significant cancer in PI-RADS v2 score 4 and 5 lesions when compared to published results using in-bore MR-guided or automated MRI-TRUS fusion guidance systems. Cancer detection was worst for TZ lesions.

Subcutaneous panniculitis-like T-cell lymphoma is a distinct variant of cutaneous T-cell lymphoma, characterized by primary involvement of the subcutaneous fat in a manner mimicking panniculitis. It accounts for less than one percent of all non Hodgkin lymphoma. We describe two such patients who presented with cutaneous nodules. A 28 year old male presented with a one and a half month history of multiple subcutaneous nodules over the thighs, abdominal wall and chest. A clinical diagnosis of panniculitis was made. An excision biopsy of one the nodules was performed and the histopathology revealed subcutaneous panniculitis-like T-cell lymphoma. The other patient was a 44 year old male who underwent excision of a subcutaneous mass in the right thigh and on histopathological examination a diagnosis of subcutaneous panniculitis-like T-cell lymphoma was made. The patients received one cycle of CHOP (cyclophoshamide, vincristine, doxorubicin and prednisolone) regimen, followed by systemic steroids and were advised follow up.

Background: Diabetes mellitus (DM) is one of the most common metabolic diseases characterized by increased blood glucose levels either due to insufficiency/absence of insulin or due to decrease in the insulin sensitivity. The prevalence of chronic kidney disease (CKD) in people with type 2 diabetes is three times higher than in non-diabetic population and majority of people developing end-stage renal diseases (ESRD) have Type 2 DM. The objectives of the study were to find out the prevalence of CKD, mean GFR and associated factors of CKD, in diabetics coming to a primary health care setting in Central Kerala.Methods: A cross-sectional study among all patients attending the NCD clinic of Health Centre, Ettumanoor with confirmed diagnosis of type 2 diabetes mellitus was done between February 2017 and April 2017.Results: The prevalence of CKD among the study population was 45.3%. The proportion of CKD was 34.9% among those with nil urinary protein, 57.1% among those with 1+ urinary protein, 88.9% for those with 2+ and 87.5% among those with 3+ urinary protein. Among those with CKD mean duration of diabetes was 121.92 months against 92.72 months among those without CKD. There was statistically significant difference between RBS values of those with CKD and without CKD (238.49 mg% versus 199.41 mg%). The proportion of CKD was found increase with duration of diabetes 5 years (31.2%), 5-10 years (47.8%), 10-15 years (52.6%) and >15 years (55%).Conclusions: The study showed high prevalence of CKD among diabetics. The duration of diabetes, urinary protein levels and RBS value were found to have strong association with CKD in diabetics.

The American Diabetic Association (ADA) has recently recommended lowering the cut-off values for the two-step oral glucose tolerance test (OGTT) used for screening of gestational diabetes. This study reports on the appropriateness of applying the latest ADA diagnostic criteria when screening for gestational diabetes mellitus (GDM) in a tertiary care facility in the United Arab Emirates. The study was carried out at Mafraq Hospital, Abu Dhabi, United Arab Emirates (UAE) between November 1999 and April 2001. A total of 889 pregnant women who underwent at least one test of the two-step OGTT were studied retrospectively for adverse maternal and fetal outcomes. Subjects were classified as GDM positive or negative by applying the old and the latest ADA criteria and the occurrence of adverse outcomes in the various groups was compared. Applying the latest ADA criteria with the two-step OGTT identified 11% & 17% more patients at risk for fetal and maternal adverse outcomes respectively. Advanced maternal age (> 30 years in our population), multi-parity (> 4) and obesity (BMI > 30) were associated with increased risk of being diagnosed as having GDM. Application of the latest ADA criteria to the two-step OGTT was determined to be appropriate for UAE pregnant women tested for GDM in the tertiary care setting. Older (age > 30 years ), multiparous ( parity > 4), and obese women ( BMI > 30 ) were at greater risk of GDM diagnosis by the latest ADA criteria. (Int J Diabetes Metab 14: 55-60, 2006)

We report the MRI features in a series of four patients with primary angiitis of the central nervous system (PACNS). Based on MRI features, clinical presentation, paraclinical investigations and laboratory tests, including cerebrospinal fluid (CSF) analysis, various differentials were considered. In two patients with MRI findings of cortical, subcortical and deep white matter lesions, lack of mass effect, focal areas of bleed and heterogeneous parenchymal, leptomeningeal or pial enhancement and a normal magnetic resonance angiography, a differential diagnosis of primary angiitis of the CNS was also considered. In all patients, an open brain biopsy was advised to establish a definitive diagnosis of PACNS. Here, we briefly discuss the MRI features, correlation with clinical presentation and paraclinical parameters for the diagnosis of this entity. We also briefly review the literature.

OBJECTIVES: Antidepressant treatment alters brain-derived neurotrophic factor (BDNF) levels, but it is not well established whether BDNF can be used as a marker to prove the efficacy of antidepressant treatment. The present systematic review and meta-analysis aim at assessing the influence of antidepressant treatment on BDNF level and the Hamilton Depression Rating Scale (HDRS) score, thereby to establish the rationale of utilizing BDNF as a predictive biomarker and HDRS score as an indicator for antidepressant treatment efficacy. MATERIALS AND METHODS: Search was conducted in PubMed, Science Direct, and Cochrane databases using the key words “BDNF” and “Depression” and “Antidepressants.” On the basis of the inclusion and exclusion criteria, studies were filtered and finally 6 randomized controlled trials were shortlisted. RESULTS: Comparison of serum BDNF level before and after antidepressant treatment was performed and the result showed that antidepressant treatment does not significantly affect the BDNF levels (confidence interval [CI]: −0.483 to 0.959; standard mean difference [SMD]: 0.238, P = 0.518). Egger's regression test (P = 0.455) and heterogeneity test (I2 = 88.909%) were done. Similarly, comparison of HDRS scores before and after antidepressant treatment indicated improvement in HDRS score suggesting positive outcome (CI: 1.719 to 3.707; SMD: 2.713, P < 0.001). Egger's regression test (P = 0.1417) and heterogeneity test (I2 = 89.843%) were performed. Publication bias was observed by funnel plot. CONCLUSION: Changes in BDNF levels do not occur uniformly for all the antidepressants. Hence, to use BDNF as a biomarker, it needs to be seen whether the same is true for all antidepressants.

Organophosphate (OP) pesticides such as dimethoate and malathion intoxication has been shown to produce oxidative stress due to the generation of free radicals and alter the antioxidant defense system in erythrocytes. It is possible that vitamin E being present at the cell membrane site may prevent OP-induced oxidative damage. In the present study, rats were pretreated orally with vitamin E (250 mg/kg body wt, twice a week for 6 weeks) prior to oral administration of a single low dose of dimethoate and/or malathion (0.01% LD 50 ). The result showed that treatment with OP increased lipid peroxidation (LPO) in erythrocytes, however, vitamin E pretreated rats administered OP's showed decreased LPO in erythrocytes. The increase in the activities of superoxide dismutase (SOD) and catalase (CAT) and total-SH content in erythrocytes from dimethoate and/or malathion treated rats as compared to control appears to be a response towards increased oxidative stress. Vitamin E pretreated animals administered OP's showed a lowering in these parameters as compared to OP treated rats which indicates that vitamin E provide protection against OP-induced oxidative stress. The glutathione-S-transferase (GST) activity in erythrocytes was inhibited in OP intoxicated rats which partially recovered in vitamin E pretreated animals administered OP's. Inhibition in erythrocyte and serum acetylcholinesterase (AChE) activity was not relieved in vitamin E pretreated rats administered OP's probably due to the competitive nature of enzyme inhibition by OP's. The results show that vitamin E may amelierate OP-induced oxidative stress by decreasing LPO and altering antioxidant defense system in erthrocytes.

Pyrethroids such as cypermethrin and fenvalerate were administered as a single dose (0.001% LD 50 ) to rats to assess their effect on oxidative stress and the antioxidant defence system in the liver, kidneys and heart tissues. Pretreatment with vitamin E, before pyrethroid treatment, was to find out whether vitamin E pretreatment would protect the rats from pyrethroid-induced oxidative stress. Lipid peroxidation (LPO) increased in the liver and kidneys in cypermethrin and/or fenvalerate treated rats; however, vitamin E pretreated rats administered pyrethroids showed a lowering in LPO. The heart tissue showed no significant change in LPO with cypermethrin or fenvalerate treatment, probably owing to hypertrophy; however, both the pesticides, when administered together, showed increased LPO. The elevated superoxide dismutase (SOD) and catalase (CAT) activities in the tissues were probably a response to the increased generation of free radicals which decreased in vitamin E pretreated rats which were administe...

Endoscopic Retrograde Cholangiopancreatography (ERCP) is an advanced endoscopic procedure in which a specialized side viewing duodenoscope is passed into the duodenum, allowing accessories to be pushed via biliary or pancreatic ducts for diagnostic and therapeutic intervention. It is one of the most complex endoscopic procedures, requiring specialized equipment and proficient and skilled operators and assistants. Today therapeutic ERCP is the intervention of choice for many pancreaticobiliary disorders. The Division of Gastroenterology & Endoscopy under the Department of Medicine has been performing ERCPs since the inception of the Endoscopy Unit in Hamad Medical Corporation (HMC), and it is the only endoscopy unit in Qatar performing ERCPs. We performed a retrospective audit of ERCPs performed over the last 5 year period from January 2006 to December 2010 in our Endoscopy unit.

Correspondence and reprint request: Natasha Chandok, MD FRCPC. Assistant Professor of Medicine. Multi-Organ Transplant Program Division of Gastroenterology. University of Western Ontario 339 Windermere Road, Room ALL 107. London, Ontario. N6A5A5 Canada Fax: 519-663-3858 E-mail: chandok.n@gmail.com Manuscript received: September 15, 2010. Manuscript accepted: October 03, 2010. January-March, Vol. 10 No.1, 2011: 103-104 LETTER TO THE EDITOR

Tracheal agenesis is a rare and uniformly lethal congenital malformation. It presents with severe respiratory distress at birth. In this anomaly there is a congenital absence of the trachea and the bronchus communicates with the esophagus. The diagnosis should be suspected in newborn infant with respiratory distress whose intubation is impossible. This report describes our experience in two such cases.

Bacillus cereusis a common cause of gastrointestinal diseases. The majority of individuals withB cereus-related food poisoning recover without any specific treatment. It can, however, rarely cause invasive disease in immunocompromised patients.

Bacterial vaginosis (BV) affects ∼ 30% of women of reproductive age, has a high rate of recurrence, and is associated with miscarriage, preterm birth, and increased risk of acquiring other sexually transmitted infections, including HIV-1. Little is known of the daily changes in the vaginal bacterial composition as it progresses from treatment to recurrence, or whether any of these might be useful in its prediction or an understanding of its causes. We used phylogenetic branch-inclusive quantitative PCR (PB-qPCR) and Lactobacillus blocked/unblocked qPCR (Lb-qPCR) to characterize longitudinal changes in the vaginal microbiota in sequential vaginal self-swabs from five women with recurrent BV, from diagnosis through remission to recurrence. Both patients with acute BV samples dominated by G. vaginalis recurred during the study with similar profiles, whereas the three patients with acute BV samples dominated by other anaerobes did not recur or recurred to an intermediate Nugent score. L. iners dominated remission phases, with intermittent days of abnormal microbial profiles typically associated with menses. The exception was a newly discovered phenomenon, a sustained period of abnormal profiles, termed conversion, which preceded symptomatic acute BV. Species known to have antagonistic activity towards Lactobacillus were detected in pre-conversion samples, possibly contributing to the decline in Lactobacillus. Lb-qPCR scores define two categories of response in the initial post-treatment visit samples; scores 8 may predict delayed or no recurrence. Amsel criteria or Nugent scores did not have this potential predictive capability. Larger studies are warranted to evaluate the prognostic potential of detecting conversion and poor Lb-qPCR scores at the post-treatment visit of recurrent BV patients.

Reflective practice has been developing as an important concept in health care and other disciplines over the last two decades. The importance of reflective practice and reflection are frequently noted in the literature, and reflective practice is regarded as an essential element in professional development. Researchers felt that it is important to assess the perceptions of students on reflection, as Gibb's model of reflection was a new concept to them. Our aim was to assess the perception and attitude of third year General nursing students of Salalah Nursing Institute on reflection and reflective practice. A descriptive study using a self administered questionnaire on perception on reflection was done. Findings revealed that students have a positive attitude towards reflective practice and reflection.

CENTRAL nervous system diseases of many types have been associated with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), 1,2 including infections, trauma, hemorrhage, and porphyria. We have recently observed a patient in whom SIADH developed following cavernous sinus thrombosis. There was no other apparent cause of excessive antidiuretic hormone (ADH) release or production. Report of a Case A 74-year-old Jamaican-born woman was admitted to another service of the hospital after two days of swelling, tenderness, and loss of vision in her right eye. She denied any trauma to the eye or head. Her previous history was unremarkable except for essential hypertension of about 20 years' duration, treated only with methyldopa. She was not diabetic and denied smoking or drinking alcohol. At admission, physical examination results showed a temperature of 38 °C and a blood pressure of 220/110 mm Hg. There were no signs of head trauma. The right