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Background Community acquired pneumonia is responsible for 16% of under 5 mortality in India, probably due to delayed recognition and qualified care seeking. Therefore these deaths could possibly be averted by creating community awareness and promoting care seeking from qualified physicians in the government system. The objective of study was to assess the effectiveness of facility-based and village-based behavior change communication interventions delivered to community using validated information, education and communication materials, along with infrastructural strengthening of health facilities, for change in care seeking from government system for community acquired pneumonia in rural Lucknow, India. Method Community based open labeled behavioral trial in 2 by 2 factorial design was conducted in eight rural blocks of Lucknow, northern India. Trained community health workers conducted Pneumonia Awareness Sessions once a month for the care givers of children using validated information, education and communication materials either at the villages or at government health facilities. Prior infrastructural strengthening of public health facilities was done to provide optimal care to cases. Pre packed pneumonia drug kits were provided which had amoxicillin, paracetamol and an instruction card on their use as well as pictorial representation of danger signs of pneumonia. Results Study lasted from October 2015 to September 2018. Adherence to conduct of facility-based intervention was 93.0% (279/300) and to village-based intervention was 73.4% (7638/10410). In village-based intervention there was 79.3% (p p = 0.02) increase from a baseline of 5.35% (21/392) in cases of possible pneumonia treated at government health facilities. Conclusion Conduct of structured pneumonia awareness session using validated information, education and communication material at village level with infrastructural strengthening resulted in improved qualified care seeking from government facilities for community acquired pneumonia. Trial registration AEARCTR-0003137, retrospectively registered on 10/July/2018.

BackgroundCommunity-acquired pneumonia (CAP) is the leading cause of under-five mortality in India. An increased risk of mortality has been reported in cases of hypoxic pneumonia.MethodsThe primary objective of this study was to assess the proportion of children aged 2–59 months, hospitalized with hypoxic CAP, as well as socio-demographic, clinical, and radiological features associated with it. The secondary objective was to determine the risk of mortality among hospitalized cases of hypoxic CAP. This prospective, observational study was conducted in four districts of Northern India, between January 2015 and April 2021. A hospital-based surveillance network was established. Inclusion criteria were as follows: (a) child between 2 and 59 months, (b) hospitalization with symptoms of WHO-defined CAP, (c) resident of project district, (d) illness of ResultsDuring the study period, 71.9% (7,196/10,006) children of severe pneumonia were eligible for inclusion, of whom 35.9% (2,580/7,196) were having hypoxic pneumonia. Female gender and use of biomass fuel for cooking increased the odds of hypoxic CAP. Clinical factors like wheezing, pallor, tachypnea, low pulse volume, presence of comorbidity, general danger signs, severe malnutrition, and radiological finding of primary end-point pneumonia ± other infiltrates (PEP±OI) also increased the odds of hypoxic CAP in a conditional logistic regression model. Adjusted odds ratio for mortality with hypoxia was 2.36 (95% CI: 1.42–3.92).ConclusionAlmost one-third of cases hospitalized with severe CAP had hypoxia, which increased chances of mortality. Besides known danger signs, certain newer clinical signs such as pallor and wheezing as well as PEP+OI were associated with hypoxic CAP. Therefore, objective assessment of oxygen saturation must be done by pulse oximetry in all cases of CAP at the time of diagnosis.

ObjectivesThe current study was a hospital-based surveillance of cases hospitalised with WHO-defined community-acquired pneumonia in children aged 2–59 months, to assess the radiological abnormalities in chest X-rays and to identify the demographic and clinical correlates of specific radiological abnormalities, in residents of prespecified districts of Uttar Pradesh and Bihar, India.DesignProspective, active, hospital-based surveillance.SettingMultisite study conducted in a network of 117 secondary/tertiary care hospitals in four districts of Uttar Pradesh and Bihar, India.ParticipantsIncluded were children aged 2–59 months, hospitalised with community-acquired pneumonia, residing in the project district, with duration of illness Main outcome measureConcordant radiological abnormalities in the chest X-rays.ResultsFrom January 2015 to April 2017, 3214 cases were recruited and in 99.40% (3195/3214) chest X-rays were available, among which 88.54% (2829/3195) were interpretable. Relevant radiological abnormalities were found in 34.53% (977/2829, 95% CI 32.78 to 36.28). These were primary end point pneumonia alone or with other infiltrates in 22.44% (635/2829, 95% CI 20.90% to 23.98%) and other infiltrates in 12.09% (342/2829; 95% CI 10.88% to 13.29%). There was a statistically significant interdistrict variation in radiological abnormalities. Statistically significantly higher proportion of abnormal chest X-rays were found in girls, those with weight-for-age z-score ≤−3SD, longer duration of fever, pallor and with exposure to biomass fuel.ConclusionsAmong hospitalised cases of community-acquired pneumonia, almost one-third children had abnormal chest radiographs, which were higher in females, malnourished children and those with longer illnesses; and an intra-district variation was observed.

Background The factors responsible for seizure recurrence in patients with Solitary calcified neurocysticercosis (NCC) are not well understood. Blood brain barrier (BBB) breach may be associated with seizure recurrence. Dynamic contrast enhanced (DCE) MRI derived indices kep, ktrans and ve are useful in quantifying BBB permeability. In this study, we assessed the possible role of DCE-MRI and matrix metalloproteinases (MMP)-9 levels in predicting seizure recurrence. Methods In this prospective-observational study, patients with new-onset seizures and a solitary calcified NCC were included. DCE-MRI was done to quantify BBB integrity. DCE-MRI parameters were measured as kep, ktrans and ve. MMP-9 levels were estimated. Patients were followed for 1 year, when DCE-MRI and MMP-9 levels were repeated. Patients were classified into two groups on the basis of seizure recurrence, which was defined as the recurrence of an episode of seizure at least 1 week after the initiation of the anti-epileptic drugs. Logistic regression analysis was done. Results At 1-year of follow up, 8 out of 32 patients had seizure recurrence. Baseline DCE-MRI derived kep (p = 0.015) and MMP-9 levels (p = 0.019) were significantly higher in the seizure “recurrence” group compared with the “no recurrence” group. On within-group analysis, a significant increase in kep (p = 0.012), ve (p = 0.012), and MMP-9 levels (p = 0.017) was observed in the seizure “recurrence” group while a decrease was seen in ve and MMP-9 levels in the “no recurrence” group. Conclusion Higher values of DCE-MRI indices and MMP-9 levels, with a corresponding trend in the follow-up, can be useful in predicting lesions with a higher propensity for seizure recurrence.

Background & Aims Data on minimal hepatic encephalopathy (MHE) in children is scarce. We aimed to study MHE in children with chronic liver disease (CLD) and to validate non-invasive objective tests which can assist in its diagnosis. Methods We evaluated 67 children with CLD (38 boys; age 13 [7–18] years) and 37 healthy children to determine the prevalence of MHE. We also assessed the correlation of MHE with changes in brain metabolites by magnetic resonance spectroscopy ( 1 HMRS), diffusion tensor imaging (DTI) derived metrics, blood ammonia and inflammatory cytokines (interleukin-6 [IL6], tumor necrosis factor alpha [TNF-α]). In addition, the accuracy of MR-based investigations for diagnosis of MHE in comparison to neuropsychological tests was analysed. Results Thirty-four (50.7%) children with CLD had MHE on neuropsychological tests. MHE patients had higher BA (30.5 [6–74] vs. 14 [6–66]μmol/L; p =0.02), IL-6 (8.3 [4.7–28.7] vs. 7.6 [4.7–20.7]pg/ml; p =0.4) and TNF-α (17.8 [7.8–65.5] vs. 12.8 [7.5–35]pg/ml; p =0.06) than No-MHE. 1 HMRS showed higher glutamine (2.6 [2.1–3.3] vs. 2.4 [2.0–3.1]; p =0.02), and lower choline (0.20 [0.14–0.25] vs. 0.22 [0.17–0.28]; p =0.1) and myo-inositol (0.25 [0.14–0.41] vs. 0.29 [0.21–0.66]; p =0.2) in MHE patients than those without MHE. Mean diffusivity (MD) on DTI was significantly higher in 6/11 brain areas in patients with MHE vs. no MHE. Brain glutamine had a significant positive correlation with blood ammonia, IL-6, TNF-α and MD of various brain regions. Neuropsychological tests showed a negative correlation with blood ammonia, IL6, TNF-α, glutamine and MD. Frontal white matter MD had a sensitivity and specificity of 73.5% and 100% for diagnosing MHE. Conclusions In children with CLD, 50% have MHE. There is a significant positive correlation between markers of hyperammonemia, inflammation and brain edema and these correlate negatively with neuropsychological tests. MD on DTI is a reliable tool for diagnosing MHE. Lay summary Fifty percent of children with chronic liver disease develop minimal hepatic encephalopathy (MHE) and perform poorly on neuropsychological testing. These children have raised blood ammonia, inflammatory cytokines and mild cerebral edema on diffusion tensor imaging as compared to children without MHE. The higher the ammonia, inflammatory cytokines and cerebral edema levels the poorer the performance on neuropsychological assessment. The estimation of mean diffusivity on diffusion tensor imaging is an objective and reliable method for diagnosing MHE.

Background: Burden of community acquired pneumonia (CAP) in infants is high in India. Streptococcus pneumoniae is stated to be an common etiological agent for it. Hence Pneumococcal Conjugate Vaccination(PCV) has been introduced in India since 2017(phased-wise). Objective: To study effect of PCV on radiological findings of chest in infants hospitalized with WHO-defined CAP. Methods: Prospective hospital-based pneumonia surveillance is ongoing since 2015 in Lucknow & Etawah districts, Uttar Pradesh and Patna & Darbhanga districts, Bihar, India. Recruitments were done from a network of hospitals formed for project. Infants(2-11months)hospitalized with WHO-defined CAP from index districts with Results: From May2017-October2018, 282(22.7%females) infants with PCV vaccination (cases) and 570 (29.8%females) without PCV vaccination (controls) with interpretable CXRs were analyzed. Primary end point pneumonia (PEP)+other infiltrate (OI) were found in 43(15.2%) cases and 140 (24.7%)controls (p=0.001);OI in 30(10.6%) cases and 69(12.1%) controls (p =0.5) and normal CXR in 209 (74.1%) cases and 361(63.3%) controls (p=0.001). There was one death among cases whose CXR showed OI. There were 22 deaths among controls whose CXRs showed PEP + OI in 12(54.6%); OI in3(13.6%) and normal7(31.8%). Crude odds ratio for death among cases was 0.088 (95 %: CI 0.012-0.66). Conclusion: Among hospitalized patients of CAP, radiological findings differ by PCV vaccination status in infants.

Background and rationale Pneumonia is responsible for about 1.4 million deaths in children under five years of age, mostly in developing countries, including India. In India, Streptococcus pneumoniae (SP) and Haemophilus influenzae (HI) are the common bacterial etiologic agents of pneumonia, and often cause abnormal chest radiology. Vaccine against HI has already been introduced in India. Pneumococcal conjugate vaccine (PCV) roll out will begin in 2017–2018 in a phased manner using Gavi funding. Objectives (1) To estimate the annual incidence of radiological pneumonia in children between 2 and 59 months of age, in prespecified districts. (2) To document the clinical and demographic characteristics of cases of WHO-defined community-acquired pneumonia (CAP) with lower chest in-drawing (LCI) and severe CAP, by establishment of hospital-based surveillance network. Study design In a prospective design, surveillance for WHO-defined radiological pneumonia in patients hospitalized for CAP is being done in two districts each of Uttar Pradesh and Bihar. For this, a pneumonia surveillance network of public and private hospitals has been established. Data are abstracted from hospital records. One copy of routine chest X-ray is also collected, digitalized, and archived electronically. An independent panel of radiologists interprets the X-rays. Five milliliters of urine of a subset of cases is being stored at −20 °C for future antigen testing. In Phase I, procedures were standardized, hospital network established, and recruitments initiated from Lucknow district. This was expanded in Phase II to include Etawah district, Uttar Pradesh and Patna and Darbhanga districts of Bihar. Progress A pneumonia surveillance network was established, having 120 health facilities in Lucknow, 60 in Patna, 64 in Darbhanga and 17 in Etawah. From 1st January 2015 to 30th April 2016, 745 CAP cases were enrolled in Lucknow. From 1st January to 30th April 2016 Patna recruited 229, Darbhanga 321 and Etawah 80 cases. Chest X-rays of all cases have been archived for interpretation by the panel of radiologists. Implications Baseline incidence of radiological pneumonia in Uttar Pradesh and Bihar will be estimated and follow-up data will enable assessment of the impact of PCV introduction.

Background: OPD is very crucial department of any hospital services as huge number of patient’s visits the OPD. Yet, the published information about patients' profile and utilization of OPD services in both developing and developed countries is scarce. The objective of our study was to study the socio-demographic profile, patient’s satisfaction towards hospital services and pattern of referral of the outdoor patients visiting Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India. Methods: It is a cross-sectional survey of patients visiting OPD in a tertiary care hospital in Lucknow. Data was collected by a structured questionnaire designed for the purpose. Results: A total of 200 patients were included in the study with average age of 40 years. The majority of patients (40%) were graduate & above. No patient was found illiterate in our study. 74.5% of the patients are currently married. 25% of the total were employed in some service, 9% were doing business. 27.5% were unemployed or students. The main presentation was Cardiac disease (20%) and Gastric problems (18.5%), followed by kidney problems (13%). 69% patients were referred to a tertiary care hospital by a doctor as a first referral. Outcome of first treatment & distance of patient’s usual place of residence from a tertiary care hospital was found to be significantly associated with referral pattern. Patient’s satisfaction towards OPD services were found to be associated with Caste, occupation, outcome of first treatment & distance of patients usual place of residence from hospital. All of the patients are highly satisfied with doctors (97%) while they were least satisfied by canteen (31.6%), transport (31.1%) & pharmacy services (25.6%). Conclusions: Overall the study showed a good level of satisfaction of patients with services obtained from this tertiary care centre. Appropriate and on-going data collection and analysis could help in optimizing utilization of outpatient services to achieve better outcomes.

Aim Improved results have made renal transplantation the favored option for treating patients with end stage renal disease. Although the risk of allograft rejection still remains a major concern for short- and long-term grafts survival, serum creatinine is the most successful biomarker to predict acute renal rejection. Methods Present analysis was carried out to assess the extent of additional risk of acute renal rejection with elevated baseline serum creatinine. Data were observed from December 2009 to April 2013 on various factors on 307 patients, who underwent renal transplant at Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS, Lucknow). Follow-up data of 90 days post-transplant were analyzed. Cox Proportional Hazards model was applied to identify the determinants of graft rejection. Survival curves for various contributing factors were obtained. Results Patients treated with cyclosporine were 3.83 times more prone to have acute rejection at 3 months than those treated with tacrolimus. Compared to those with creatinine Conclusions Renal transplant cases with elevated creatinine at two weeks post-transplant and those on cyclosporine-based immunosuppression are at higher risk of acute rejection and would require more frequent follow-ups and monitoring to diagnose early acute rejection episodes.

Structural imaging of the brain does not demonstrate any changes in a vast majority of patients with vitamin B12 deficiency, even in advanced stages. In this study, we aimed to assess and correlate the functional integrity of the brain fiber tracts using diffusion tensor tractography with neuropsychological examination in patients with vitamin B12 deficiency. The study was conducted at two tertiary care centers. Thirty-two patients with vitamin B12 deficiency were enrolled and subjected to diffusion tensor tractography, as an extension of diffusion tensor imaging, and neuropsychological assessment. Tests of significance were done to detect changes, pre- and post-vitamin B12 supplementation in the diffusivity parameters (fractional anisotropy and mean diffusivity) and the neuropsychological test scores. Statistically significant changes were observed in the diffusivity parameters and the neuropsychological test scores between the controls and the patients with vitamin B12deficiency in the pre- and post-treatment phases. This is the first study to evaluate the diffusion tensor tractography (DTT) parameters in the light of clinical neuropsychological assessment in patients with vitamin B12 deficiency. Utilization of DTT parameters may antedate structural changes and may quantify the neurocognitive deficits.

Presently, there is no published study that shows association between cognition and white matter injury in spastic cerebral palsy. We aimed to correlate cognitive functions with diffusion tensor imaging derived metrics in spastic diplegic children.Twenty-two term children with spastic diplegia and 22 healthy controls were recruited. All patients were graded on the basis of gross motor function. The Indian children intelligence Test was used to quantify cognition and diffusion tensor imaging was used to quantify microstructural changes in various white matter regions. Diffusion tensor imaging metrics were quantified by placing regions of interests in different white matter regions like corona radiata, anterior limb of internal capsule, posterior limb of internal capsule, mid brain, pons, medulla, genu, splenium, temporal white matter, parietal white matter, frontal white matter and occipital white matter.Spastic diplegic children showed significantly lower neuropsychological test scores as compared to controls. A significantly decreased fractional anisotropy values were observed in corona radiata, anterior limb of internal capsule, posterior limb of internal capsule, mid brain, pons, medulla, genu, splenium and occipital white matter; however significantly increased mean diffusivity values were observed in corona radiata, anterior limb of internal capsule, posterior limb of internal capsule, mid brain, pons and genu in spastic diplegic as compared to controls. A significant positive correlation in fractional anisotropy and negative correlation in mean diffusivity was observed with neuropsychological test scores.These results suggest that these imaging metrics may be used as a biomarker of cognitive functions in term children with spastic diplegia.

Objectives: In patients with neurocysticercosis, perilesional inflammatory activity is thought to be responsible for seizures. This study was designed to evaluate the serum and cerebrospinal fluid (CSF) concentrations of cytokines as well as matrix metalloproteinase (MMP)-2 and MMP-9 in patients with a solitary cysticercus granuloma. Materials and Methods: The study included 47 patients suffering from seizures in whom a solitary cysticercus granuloma was detected on a computed tomography (CT) scan. The study also included 47 control subjects. Their serum and cerebrospinal fluid (CSF) was analysed for cytokines and MMP levels. A follow-up CT was performed after 6 months. Results: The median levels of cytokines, interleukin (IL)-1β, IL-5, IL-6, IL-10 and tissue necrosis factor (TNF)-α, MMP-2 and MMP-9 were significantly elevated, both in the serum and CSF of patients having an intracerebral solitary cysticercus granuloma, in comparison to that of controls. The follow-up CT revealed that in 27 patients, the lesions were calcified and in 5 patients, there was complete resolution of the lesions. In 15 patients, the lesions remained unchanged. Higher baseline CSF MMP-2 and TNF-α level were seen in patients with persisting lesions. Higher serum baseline MMP-2, IL-6 and a low CSF IL-10 level were seen in patients with complete resolution of the granuloma. A high baseline IL-1β level was associated with a calcified lesion. Fourteen patients had recurrence of seizures. A high baseline serum TNF-α level was independently associated with seizure recurrence (P = 0.021, OR = 1.041, CI = 1.006 to 1.078). Conclusion: In patients with a solitary cysticercus granuloma, cytokines and matrix metalloproteinases in the CSF and serum are elevated. Different patterns of immunological changes were observed in patients following resolution or calcification of the lesion.

This paper examines the extent of variation in the applicator geometry during multiple high dose rate (HDR) intracavitary brachytherapy (ICBT) applications and its impact on reporting as per ICRU report 38.Eighty orthogonal radiographs from 20 consecutive patients of carcinoma cervix (FIGO stages, IIA-IIIB) having four HDR ICBT applications of 6 Gy each at weekly intervals following teletherapy were evaluated. The applicator consisted of a flexible intrauterine tandem (IUT) independent of the ovoid assembly. The applicator geometry was evaluated in terms of: alpha angle, beta angle, intrauterine length (IUTL), interovoid (IOV), os to right ovoid (ORT) and os to left ovoid (OLT) distances along with vertical (VDL) and anteroposterior displacements (ADL) of the os with respect to the ovoids. The Cartesian co-ordinates (X, Y, and Z) of the IUT tip, centre of both ovoids and os were also measured. Doses to right point A (ARD), left point A (ALD), along with a reference volume of 6 Gy for ICRU height (IRH), width (IRW), thickness (IRT) and volume (IRV) were estimated for each application.Highly significant differences (P0.001) between four insertions in any given patient across 20 patients for alpha angle, beta angle, IUTL, IOV, ORT, VDL, co-ordinates of the IUT, ovoids and os were observed, except for ADL (P=0.041) and OLT (P=0.247). As a consequence, variations were observed in ARD (P=0.027), ALD (P=0.017); IRH, IRW, IRT and IRV (all P0.001). Applicator factors which influenced the various dose specification parameters were: beta angle and ORT for both ARD and ALD; UTLN, VDL and ORT for IRH; UTLN and IOV for IRW; UTLN for IRT and VDL for the 6 Gy IRV.A significant variation of the applicator geometry and its movement was observed in patients undergoing multiple HDR ICBT. This could have implications for reporting dose and volume specifications as required by ICRU report 38.

A diagnostic test is any kind of medical test performed to determine the presence or absence of a disease when a subject shows signs or symptoms of the disease. Measures of diagnostic accuracy tell us about the ability of a test to discriminate between disease and health. There are many measures used to show the accuracy of the diagnostic test including sensitivity, specificity, etc. We calculate these measures in 2×2 table, comparing with gold standard and it is possible only when result of the gold standard as well as new test is dichotomous nature. Many diagnostic test results have continuous scale and for such variable a series of cutoff points for disease and corresponding measures of accuracy can be calculated using receiver operating characteristics curve. In this article, we have discussed the various measures of diagnostic accuracy and their computational methods commonly used to assess the performance of a diagnostic test.

Records of 103 patients with constrictive pericarditis who underwent subtotal pericardiectomy from January 1990 to December 1997 were retrospectively analyzed. The etiology of pericardial constriction was unknown in 63, tuberculous in 30, pyogenic in 7, and miscellaneous in 3 patients. Adequate pericardiectomy could be accomplished in 85 (82.5%) patients. Eleven patients (10.68%) died within 30 days of surgery. The 92 survivors were followed up for 47.21 ± 30.7 months; functional status improved in all cases. Of 15 variables examined by univariate logistic regression analysis, preoperative New York Heart Association functional class IV, atrial fibrillation, left atrial size > 40 mm·m−2, mild to moderate mitral regurgitation, tricuspid regurgitation, pericardial calcification, and inadequate pericardiectomy were found to be significant predictors of poor outcome. Adequate pericardiectomy via sternotomy was considered to carry low operative risk and provide excellent improvement in functional capacity.

Owing to the small quantity of tissue available in human biopsy specimens, aqueous and lipid components often have to be determined in the same tissue sample. Perchloric acid (PCA) used for the extraction of aqueous metabolites has a deleterious effect on lipid components; the severity of the damage is not known. In this study, human muscle tissue was first treated with PCA to extract aqueous metabolites, and the residue was then used for lipid extraction by conventional methods, i.e. the methods of Folch and Bligh & Dyer and a standardised one using methanol/chloroform (1:3, v/v) used in our laboratory. A 1H-NMR spectrum was obtained for each lipid extract. Lipid was quantified by measuring the integral area of N+-(CH3)3 signals of phospholipids (PLs). Triacylglycerol (TG) and cholesterol (CHOL) were quantified using the -CH2- signals of glycerol and the C18 methyl signal, respectively. This study shows that prior use of PCA caused marked attenuation of TG, PL, and CHOL. This was confirmed by recovery experiments and observation of the direct effect of PCA on the standard lipid components. On the basis of the quantity of lipid lost in each case, three novel equations (with respect to TG, PL, and CHOL) were derived. Application of these equations to lipid quantities estimated in different pathological tissues after PCA pre-treatment produced values equivalent to those estimated without PCA use. This study conclusively shows that PCA pre-treatment damages all three lipid moieties, TG, PL, and CHOL. When PCA is used in a fixed ratio to the tissue, the lipid damage is also proportional and correctable by statistically derived equations. These equations will be useful in human biopsy specimens where aqueous and lipid components have to be studied using the same tissue sample because of the small quantity available. Copyright © 2007 John Wiley & Sons, Ltd.

An open controlled trial of 0.75 mg/Kg/day prednisolone was conducted at a stage when the patients had started falling several times in a day and stopped on their attaining a chair bound stage, thus minimising the total period of steroid therapy. Out of the 67 DMD patients enrolled in this study, 44 were put on prednisolone therapy and 23 served as controls. All patients were followed-up at two-monthly intervals for two years and thereafter they continued to take their respective medications till their chair-bound stage; then the drug was gradually withdrawn. In the treatment group 24 patients could not continue the trial because of adverse effects – 14 due to excessive obesity, 3 due to measles, 4 due to pulmonary tuberculosis, 2 due to recurrent throat and chest infection and 1 due to an unexplained high leukocyte count. Of the remaining 20 patients in the treatment group, steroid therapy was stopped in 5 patients as there was no improvement in power in six months. Fifteen patients in the treatment group and 19 patients in the control group could be followed regularly for 2 years and then up to chair-bound stage. Outcome parameters included fall frequency, peak expiratory flow rate, limb muscle power, ability to lift weights, time taken in getting up from squatting position, walking 9 metres and climbing 13 stairs. Maximum improvement was noted between 2 and 4 months while mild improvement in some parameters continued up to six months. All parameters remained stabilised for 1 year or so, after which there was slight deterioration. Deterioration at 2 years was, however, less than the natural course of events noted in control patients. Prednisolone treated patients and controls became chair bound at the mean age of 169 ± 9 and 132 ± 8 months respectively. Till the ideal stage of the disease and the type or dosage of starting steroid therapy is defined by specially designed studies, 0.75 mg/Kg/day prednisolone therapy may be started in DMD patients at the stage of frequent falls ( > 10 / day) on walking or increased get-up time ( > 10 s) as observed while testing Gowers’ sign; this improves muscle power and timing of motor performance within 2–4 months of onset of therapy in about 75% of those who tolerate this therapy, with a possible gain of approximately 3 years in terms of independent walking.

Insertion of cranial pins for stabilization of the head can result in a marked hypertensive response, which may adversely affect cerebral hemodynamics. The efficacy of a subanesthetic dose of intravenous ketamine (0.5 mg/kg) and/or lidocaine infiltration (1%) at pin fixation sites before pinning was studied in a prospective, double-blind, placebo-controlled, randomized trial of 40 patients. The subjects were divided into four groups of 10. Patients belonging to the placebo and lidocaine groups received intravenous normal saline (NS), followed by local infiltration with NS at pin insertion sites in the placebo group and 1% lidocaine in the lidocaine group. Patients belonging to the ketamine and ketamine-lidocaine groups received intravenous ketamine followed by local infiltration with NS in the ketamine group, and lidocaine infiltration in the ketamine-lidocaine group. Heart rate (HR) and invasive mean blood pressure (MBP) were recorded before intravenous medication and then at various time intervals until 15 minutes after pin fixation. Intergroup comparison of MBP and HR by 2-way analysis of variance revealed a significant difference between the groups and various time points (P.05). Post hoc analysis revealed maximum increase in MBP each hour in the placebo group. Mean blood pressure response in the ketamine group was similar to the placebo group. Significant attenuation of MBP and HR was observed in the lidocaine and ketamine-lidocaine groups (P.05). A minimal increase in HR was observed in the lidocaine-ketamine group. The current study demonstrates maximum attenuation of hemodynamic responses when a subanesthetic dose of intravenous ketamine (0.5 mg/kg) is administered with 1% lidocaine infiltration.